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LSVT Global® Public Webinar Series
Title: LSVT LOUD® and LSVT BIG® Mythbusters: What you need to know!
Presenters: Elizabeth Peterson MA, CCC-SLP
Laura Gusé, MPT
Date Presented: January 16, 2019
Copyright:
The content of this presentation is the property of LSVT Global and is for information purposes only. This content should not be reproduced without the permission of LSVT Global.
Contact Us:
Web: www.lsvtglobal.com Email: [email protected]
Phone: 1-888-438-5788 (toll free), 1-520-867-8838 (direct)
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LSVT LOUD® and LSVT BIG® Mythbusters:
What you need to know!Elizabeth Peterson, MA, CCC‐SLP
LSVT LOUD Training and Certification Faculty
LSVT Global, Inc.
Laura Gusé, MPT
LSVT BIG Chief Clinical Officer
LSVT Global, Inc.
Innovation in Science. Integrity in Practice.
All of the LSVT LOUD and LSVT BIG faculty have both financial and non‐financial relationships with LSVT Global.
Non‐financial relationships include a preference for LSVT LOUD and LSVT BIG as treatment techniques.
Financial Relationships include:
Ms. Peterson and Ms. Gusé are employees of and receive lecture honorarium and travel reimbursement from LSVT Global, Inc.
Disclosures
Plan for Webinar
• Logistics
• Presentation of content
• Address your questions
• Survey
Instructor Biographies
Elizabeth Peterson, MA, CCC‐SLP
Ms. Peterson received her master’s degree in Speech, Language and Hearing Sciences from the University of Colorado‐Boulder. She began working with Dr. Lorraine Ramig’s research team while completing her master’s thesis. Ms. Peterson is LSVT LOUD certified and primarily delivers LSVT LOUD in the research setting. She has worked as a research associate at the National Center for Voice and Speech‐Denver and the University of Texas Health Science Center, San Antonio. Ms. Peterson is currently involved in Dr. Ramig’sresearch investigating the short and long‐term impact of LSVT LOUD on neural underpinnings of speech in Parkinson disease.
Laura Gusé, MPT
Ms. Gusé received her Master’s Degree in Physical Therapy from the University of North Dakota. She has over 15 years of experience working with adults with neurological disorders with a special focus on Parkinson disease and Multiple Sclerosis. She has been certified in LSVT BIG® since 2009, and has been a Multiple Sclerosis Certified Specialist. She is an LSVT BIG faculty member and Clinical Expert, and has helped to develop many of the current LSVT BIG treatment tools and videos, webinars and curriculum. She now serves as the Chief Clinical Officer of LSVT BIG.
Objectives of Presentation
Discuss importance of research evidence and dissemination of
accurate information
Discuss common misperceptions related to LSVT LOUD and LSVT BIG
Provide clarifying statements to address misperceptions related to
LSVT LOUD and LSVT BIG
List strategies to help overcome challenges to implementation
Polling QuestionWho are you?
• Speech Therapist
• Physical or Occupational Therapist
• Other Medical Professional
• Person with PD
• Other
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Who are we?
Our Mission
To empower people with Parkinson’s
to restore and maintain their highest
levels of functional communication,
mobility and independence with ADL’s
through scientifically supported
rehabilitative treatment programs:
• LSVT LOUD®
• LSVT BIG®
Research is essential to provide the strong foundation we need as
therapists!
Our work – LSVT Protocols:Based on 25 years of NIH funded research
and clinical experience
LSVT LOUD is a speech therapy
Delivered by LSVT LOUD Certified
Speech‐Language Pathologists
LSVT BIG is a physical/occupational
therapy
Delivered by LSVT BIG Certified Physical or
Occupational Therapists
20+ year journey from invention to scale‐upOver 8 million dollars in NIH funding
1987‐89: Initial invention; Pilot data (Scottsdale)1989‐91: Office of Education OE‐NIDRR
1991‐94: OE‐NIDRR1990‐95: NIH funded RCT Efficacy1995‐00: NIH funded EMG, Kinematics2002‐07: NIH funded RCT Spread of effects2007‐12: NIH funded RCT, imaging
2001‐02: Coleman Institute (PDA; LSVTC)2002‐04: NIH and M J FOX Foundation PDA (R21)2002‐04: Coleman Institute (VT; LSVTVT)2004‐06: NIH LSVTVT (R21)2004 : Coleman Institute (LSVT Down Syndrome) 2004‐07: LSVT –Dissemination2006: Technology‐enhanced Clinician Training (SBIR)2010: Technology‐enhanced LSVT LOUD delivery (SBIR)
Phas
e I,
IIPh
ase
IIIPh
ase
IV, V
What are the fundamentals of LSVT LOUD and LSVT BIG?
TARGET: Loudness/bigness (amplitude)
MODE: Intensive and High Effort60 minute INDIVIDUAL sessions
4 sessions per week for 4 weeks
CALIBRATION: GeneralizationSensoryInternal cueingNeuropsychological changes
Standardized, research-based, specific protocol
Ramig et al., 2001; J Neurol, Neurosurgery, PsychiatryLevel 1 Evidence Goetz,2003
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Months
SPL Rainbow (5
0 cm)
LSVT R
LSVT® LOUD
RESP
N=45
Blinded, no med changeSame time med
Comparing Exercise in Parkinson’s Disease —The Berlin LSVT BIG Study (2010, Movement Disorders)
Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1Andreas Kupsch,2 and Jo¨rg Wissel
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FIG. 2. UPDRS motor score (blinded rating), mean change from baseline (vertical bars 5 standard deviations). Change between baseline and follow up at week 16 was superior in BIG (interrupted line) compared toWALK (dotted line) and HOME (solid line), P <0.001. ANCOVA did not disclose significant differences between in intermediate and final assessments.
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What are the LSVT LOUD exercises?Daily tasksFirst half of treatment sessionRescale amplitude of motor output through CORE Loud
Sustained “ah” (minimum15 reps) High/Low “ah” (minimum15 reps) Functional phrases (minimum 50 reps)
Hierarchical speech tasks Second half of sessionTrain amplitude from CORE exercises into in context specific and variable speaking activities
Week 1 – words, phrasesWeek 2 – sentencesWeek 3 – readingWeek 4 ‐ conversation
Shorter, simple
Longer, more complex
LSVT BIG Treatment Session
Maximal Daily Exercises
1.Floor to Ceiling – 8 reps
2.Side to Side – 8 each side
3.Forward step – 8 each side
4.Sideways step – 8 each side
5.Backward step – 8 each side
6.Forward Rock and Reach – 10 each side (working up to 20)
7.Sideways Rock and Reach – 10 each side (working up to 20)
Walking BIG
Distance/time may vary
Functional Component Tasks
5 EVERYDAY TASKS– 5 reps each
For example:
‐Sit‐to‐Stand
‐Using cell phone
Hierarchy Exercises
Patient identified tasks: Getting out of bed, Playing golf, Getting in and out of a car
Build complexity across 4 weeks of treatment towards long‐term goal
Homework
Includes all daily exercises, Functional Component Tasks and BIG walking assigned all 30 days
Translation ofPulling keys out of pocket
Implementation & Knowledge Translation: The of the Matter!
Misperceptions about beneficial treatment interventions can cause patients to forfeit the GIFT of life changing results!
Be informed, educate yourself and others on FACTS!
What do you hear? Definition of Myth:
“an unfounded or false notion”
Definition of Misperception:
“a false or inaccurate perception”
from Merriam‐Webster Dictionary https://www.merriam‐webster.com/dictionary/myth
https://www.merriam‐webster.com/dictionary/misperception
Types of Common
Misperceptions
Applicability
Accessibility
Dosage
Reimbursement
Standardization
Expected Outcomes
Misperceptions on Applicability
1. LSVT LOUD and LSVT BIG are only for people with early to moderate Parkinson disease (PD). They too intensive for people with advanced PD.
2. LSVT LOUD and LSVT BIG are not intensive enough (too easy) for people with early PD.
3. You must have a diagnosis of PD to be eligible for LSVT LOUD or LSVT BIG.
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Misperceptions on ApplicabilityMisperception Clarifying Statement Solutions
LSVT LOUD and LSVT BIG are only for people with early to moderate Parkinson disease (PD). They are too intensive for people with advanced PD.
Patients with advanced PD, due to increasing problems with memory, attention, processing, and motor learning, benefit even more from repetition and training to learn a skill.
Within the treatment, intensity is scaled for exercise that is medically safe and takes into account potential co‐
morbidities.
Focus remains simple and redundant!
Customized treatment plan and goals to specific to patient’s needs (e.g. focus on basic ADLs, communication and mobility for basic needs and safety)
Complete entire LSVT LOUD protocol –adapt exercises as needed (e.g. reduced reps)
View On Demand webinars:Atypical and Advanced Parkinsonian Disorders: An Overview and Discussion of Application to LSVT LOUD®
Atypical and Advanced Parkinsonian Disorders: An Overview and Discussion of Application to LSVT BIG®
Misperceptions on ApplicabilityMisperception Clarifying Statement Solutions
LSVT LOUD
and LSVT
BIG are not
intensive
enough (too
easy) for
people with
early PD.
Patients with early PD benefit from additional challenges (dual motor and cognitive) to drive neuroplasticity and optimize “real world” function. Goals: Slow symptom progression, prevent decline and secondary impairment, maintain function and participation in communication and occupational roles.
LSVT LOUD and LSVT BIG should never be easy or boring!
Clinicians add challenges: increase reps, duration, dual cognitive and motor tasks, speed, resistance, balance challenges, agility, endurance, etc.
Clinicians include salient tasks related to occupation/community involvement.
View On Demand webinars: • Early Parkinson Disease: A discussion on
the benefits of exercise and LSVT LOUD®• Early Parkinson Disease: A discussion on
the benefits of exercise and LSVT BIG®• Am I too early to start LSVT BIG® or LSVT
LOUD®?
Misperceptions on ApplicabilityMisperception Clarifying Statement Solutions
You must
have a
diagnosis
of PD to
be
eligible
for LSVT
LOUD or
LSVT BIG.
You do not need a diagnosis of PD to receive LSVT LOUD or LSVT BIG. A combination of history, examination, stimulability testing, clinician judgement and 1 week of trial treatment is used to determine applicability to diagnoses beyond PD.
Chart Review: Is intensive exercise medically safe? Any contraindications? Do I need physician clearance?
Lit Review: blog.lsvtglobal.com/research/neurological‐references/
What is the response to stimulability testing? Improved volume and/or other aspects of communication, bigger and better movements?
What is response after week of treatment?
View On Demand Webinar: LSVT LOUD® and LSVT BIG® Beyond Parkinson Disease: Could they be helpful for my condition?
Additional Misperceptions on Applicability Which Patients
May Have
• I was just diagnosed and don’t have anyproblems with my voice, mobility or balance.
• I am very physically fit and exercise often so I don’t need LSVT BIG or LSVT LOUD.
• I’ve had “BIG” or “LOUD” for a few visits and it did not work.
• LSVT BIG and LSVT LOUD are just a simple set of exercises that you can learn from the Homework Helper DVDs.
• Intensive exercise groups are adequate or a better choice for people with early PD
Additional Applicability Solutions
• Use and improve it! Don’t wait until it’s broken
• Educate: Exercise and therapy are complementary!
• View On Demand Webinars:
• Exercise versus Therapy for PD: How do Idecide?
• Exercise is great, but how will that improve my function?
• https://blog.lsvtglobal.com/public‐webinars/ Misperceptions on
Accessibility
In rural populations it is never feasible for people to make a lengthy commute to a clinic 4 days a week.
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Clarifying Statements on Accessibility
We acknowledge there can be challenges to commuting to a clinic 4 times per week, whether it be distance, mobility, transportation issues or otherwise.
We have also seen these barriers overcome through creative solutions and education on importance of intensive dosage.
Solutions
• Temporary stay with someone close to the clinic
• In home therapy – “outpatient”
• Team of drivers
• Advocate for clinicians to get trained in rural areas. LSVT LOUD and LSVT BIG can be used for more than PD!
• Utilize technology: LSVT Companion, LSVT eLOUD
• Education on importance of intensive dosage
Misperceptions on Dosage
The dosage is too high. LSVT LOUD and LSVT BIG can be completed in fewer or shorter sessions.
• Patients will not be able to come to treatment four times per week for four weeks.
• The clinic I go to only allows providers to see patients for 45‐minute sessions.
• I work part‐time, so I am not able to complete the full protocol.
Clarifying Statements on Dosage
The research on LSVT BIG and LSVT LOUD, including 4 RCTs, all show that dosage is effective. We have no evidence to show that a lower dose can be just as effective, so why risk it and lower the dosage, if you have no idea if it will work?
A pharmacist would never alter the dosage of a medicine on his/her own when there is RESEARCH on that drug, which has shown that a specific dosage is optimal for treatment of the symptoms. Exercise IS medicine!!
Clarifying Statements on Dosage
Dosage is important in neurorehabilitation because the literature on neuroplasticity and motor learning underscores the need for training that is sufficiently intense, frequent and repetitive.
The same principles that make athletes excel at their sports apply to people who are “fighting” Parkinson’s!
Clarifying Statements on Dosage
In addition to behavioral changes, neural changes have also been documented in the literature, post‐LSVT LOUD.
These data document that intensive exercise, in this case of the voice mechanism, can have an impact on neural functioning. Narayana et al., 2010
Activation Pattern During Paragraph Reading
PRE
POST
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Patient Dosage SolutionsMyth: Patients will not be able to come to treatment four times per week for four weeks.
Many will once educated! Often remark “time flies!”
• Short “burst” of treatment better than continuous, low dosage of treatment
• 16 hours is not so long when looking at the big picture
Utilize technology: LSVT Companion, LSVT eLOUD
Clinician Dosage Solutions My clinic only allows us to see patients for 45‐minute sessions.
• Educate administrators on importance of intensive dosage (Ramig, et al., 1995; Ramig et al., 2001; Fox et al., 2002; (Ebersbach, 2010; Ebersbach 2014)
Provide 1‐2 slots for LSVT LOUD or LSVT BIG per month
Run LSVT LOUD or LSVT BIG camps (e.g. one month of only LSVT LOUD or LSVT BIG patients)
• LSVT BIG: Recognize that 180 minutes = Three 60 minute slots or four 45 minute slots. Reimbursement is time based, so 180 minutes = 180 minutes.
• Utilize the LSVT Companion for some at‐home LSVT LOUD sessions (Halpern et al., 2012)
• YOU are the professional!
I work part‐time, so I am not able to complete the full protocol.
• Share a patient with another LSVT LOUD or LSVT BIG Certified Clinician (we recommend no more than two clinicians per patient)
• Utilize the LSVT Companion for some at‐home LSVT LOUD sessions (Halpern et al., 2012)
Misperceptions on
Reimbursement
• You cannot provide LSVT BIG or LSVT LOUD per protocol because of the Medicare therapy thresholds, especially if they have received other PT or Speech Therapy in the same year
• LSVT programs cannot be reimbursed in the home health setting when delivered per protocol
Misperceptions on Reimbursement
Misperceptions Clarifying Statements Solutions
LSVT LOUD
and
LSVT BIG
are not
reimbursable.
LSVT programs are reimbursed in the US and around the world.
LSVT LOUD and LSVT BIG training and continued support provides best practice recommendations for outcomes and documentation which positively support reimbursement.
There is no Medicare therapy cap.
Training course provides many resources for documentation statements and commonly reported codes as well as sample goals and templates for treatment and assessment reports/notes
Advocate and educate!
Contact our LSVT Expert Faculty! [email protected]
View On Demand webinar:Crucial Questions: Insurance Coverage and Considerations for LSVT LOUD® and LSVT BIG®
Misperceptions on
Standardization
LSVT LOUD and LSVT BIG are too standardized and not customizable.
• How can I personalize treatment if I need to follow the same protocol for every patient?
• I worry that I will get bored with the repetition.
• I’m concerned I won’t be able to use my clinical skills.
Clarifying Statements on Standardization
The standardized LSVT protocols are supported by years of research and incorporates principles
of neuroplasticity and motor learning.
However within this structured protocol, there is customization of treatment activities to
personalize and tailor goals to each person.
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Clarifying Statements on Standardization
People with PD need even MORE repetition as the non‐motor symptoms of PD affect learning, attention, procedural memory and more.
Clarifying Statements on Standardization
While the protocol is standardized and the target of treatment is vocal loudness, the
therapist is constantly using clinical skills and knowledge to shape the patient’s output into the best possible voice and functional movement.
Standardization SolutionsHow can I personalize treatment if I need to follow the same protocol for every patient?
Saliency is a key principle of neuroplasticity –personalize your materials!
Goals and activities are based on patient’s needs and desires
Examples of Early PD Goals:
• LSVT LOUD: Client will be able to effectively project voice during business meetings and phone calls
• LSVT BIG: Client will be able to walk over uneven terrain and safely climb ladders while talking so that patient can safely continue to work as a construction manager.
Examples of Advanced PD Goals:
• LSVT LOUD: Client will be able to communicate needs over telephone in case of emergency.
• LSVT BIG: Client will be able to get out of bed independently and walk to the bathroom without freezing or shuffling to allow for safety when using the toilet at night.
https://leader.pubs.asha.org/article.aspx?articleid=2677949
Standardization Solutions
• Personalize materials and exercises so they are salient
• Add challenges as progress – e.g. motor and cognitive dual taskingBe engaging! Patients feed off your energy!
I worry that my patient will get bored with the repetition.
• The focus is simple for the patient (LOUD/BIG), but complex for the clinician (e.g. constantly assessing, redirecting, modeling, shaping, calibrating) in order to find the best voice/movement for each patient on any given day and making that voice last!
• How can you PUSH the patient further?
I’m concerned I won’t be able to use my
clinical skills.
Misperceptions on Expected Outcomes
LSVT LOUD teaches patients to shout and LSVT BIG makes people move in an exaggerated way.• Patients will sound or look unnatural because they will be talking too loud or moving too big.
• I will not benefit from LSVT LOUD because I am concerned about articulation, not loudness.
• Patients are at an increased risk for hyperfunctionalbehaviors when asked to get loud.
• LSVT BIG does not help with fine motor skills.
• LSVT BIG only helps with walking.
Clarifying Statements on Expectations
Although we use the word “LOUD” and “BIG”, the treatment goal is always to scale up the voice and movement that is normal in amplitude and NOT exaggerated.
Because of the effects of PD on the sensory system, a quiet voice and smaller movement many times feels normal to the person with PD, thus, in order to help people with PD “rescale” to normal loudness and movement, we have to increase the amplitude. To the person with PD this may feel “LOUD” or “BIG” but the voice and movement is trained to be at a normal level.
The skill of the therapist is critical in shaping amplitude that is “just right”. Certified Clinicians are trained to increase loudness and movement in a healthy, safe way, which results in normal amplitude with good quality, and normal volume and movement.
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Solutions on ExpectationsMyth: Patients will sound or look unnatural because they will be talking too loud or moving to big.
Solution: Education on sensory deficits
• Loudness diagram/Relative amplitude diagram
• “If it feels too loud/big, it’s just loud/big enough!”
Reassure patients you will never let them leave with a voice that sounds funny or is overly loud or movement that looks funny or is overly big.
e.g. Lots of recording and playback
Solutions on Expectations
Review and share the
literature on the spread of
effects of LSVT programs
• LSVT reference list:
blog.lsvtglobal.com/
research
• Keep focus on
loud/big spread
of effects will follow!
Logemann(swallowing)
Smith, M.(adduction)
Ramig & Dromey(aerodynamics)
Baker, Luschei(EMG)
P. Fox, Liotti(PET)
Dromey, Ramig &Johnson
Sapir et al(articulatory acoustics)
Smith,A.(STI)
Taskoff &Ramig
(perceptual)
Huber, Stathopoulos(respiratory kinematics)
Myth: I will not benefit from LSVT LOUD because I am concerned about articulation, not loudness.
Myth: I will not benefit from LSVT BIG because I am concerned about speed, fine motor skills, or activities of daily living, but not amplitude.
Solutions on Expectations
Misperception: Patients are at an increased risk for hyperfunctional behaviors when asked to get loud.
• Literature documents that LSVT LOUD exercises do not create hyperfunction. (Smith et al., 1995; Countryman et al., 1997)
• Never sacrifice quality for loudness, always working toward healthy vocal loudness
• Clinicians use clinical/knowledge and skills to shape for optimal voice
SummaryIt is important that providers and patients are informed of the research on LSVT programs and accurately educate others so that patients receive the highest quality of care.
We know there are challenges to implementation in the “real‐world” but these challenges can be overcome!
We are here to help you receive the best possible LSVT program!
We want to hear from you!What types challenges or misperceptions
are you encountering?
1. Type in the QUESTION BOX on your control panel
2. Raise your hand! (Click on the hand icon.)
• Your name will be called out
• Your mic will be unmuted (make sure your mic is unmuted as well)
• Then ask your question out loud
3. Email [email protected] if you think of questions later
How to ask questions LIVE:How Do I Locate
LSVT Certified Clinicians?
1. www.lsvtglobal.com
2. Click on
3. Advanced Search Options
• LSVT LOUD (Speech Therapy)
• LSVT BIG (Physical & Occupational Therapy)
4. Enter location
5. Select radius
5. Check “I agree to the terms and conditions”
6. SEARCH
FIND LSVT CLINICIANS
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Upcoming LIVE LSVT BIG® Certification Courses:• Jacksonville, FL January 26‐27, 2019• Nashville, TN February 23‐24, 2019• Cherry Hill, NJ March 8‐9, 2019• Milan, Italy, March 9‐10, 2019• Birmingham, UK March 23‐24, 2019
Upcoming LIVE LSVT LOUD® Certification Courses:• Durham UK March 21‐22, 2019• Livonia, MI May 4‐5, 2019
People with PD and Guests Invited!2 hour free seminar from 12 noon – 2:00 PM on DAY 2
https://blog.lsvtglobal.com/events/category/free‐educational‐seminars/
QUESTIONS??
Next Webinar: Spread of Effects of LSVT LOUD: More than Increased LoudnessDate: Wednesday, February 20, 2019Time: 2:00 PM – 3:00 PM Eastern Standard Time
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