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

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

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

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

6. Dopamine and Neurons

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

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

9. Extrapyramidal System
“Automatic System”

10. Pyramidal
“Intentional System”

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

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

13. SPEAK OUT! & LOUD Crowd

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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