LOUD): What is it?

2/13/2015 Expanding LSVT: Treating Acquired Dysarthria Following Pediatric Brain Injury Jennifer P. Lundine & Katie Kubitskey ………………..……………………………………...
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2/13/2015

Expanding LSVT: Treating Acquired Dysarthria Following Pediatric Brain Injury Jennifer P. Lundine & Katie Kubitskey

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Expanding LSVT: Treating Acquired Dysarthria Following Pediatric Brain Injury Jennifer P. Lundine , MA, CCC-SLP, BC-ANCDS & Katie Kubitskey, BA Presented March 20, 2015 Ohio Speech-Language-Hearing Association State Conference Columbus, Ohio

Katie Kubitskey has no financial or non-financial disclosures to report. Jennifer Lundine reports that she is LSVT-certified, but has no other disclosures to report. ………………..……………………………………………………………………………………………………………………………………..

Lee Silverman Voice Treatment (LSVT/LOUD): What is it? • Originally designed & validated for individuals with hypokinetic dysarthria due to Parkinson’s Disease (PD) • Therapy delivered intensively •4 days per week for 4 weeks •Hour-long sessions •Specific homework and carryover activities • Single treatment target = increase loudness ………………..……………………………………………………………………………………………………………………………………..

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LSVT: Background & premises • Intensive, single-target, high-effort exercise • Taught across simple to complex, functionally relevant speech tasks • Consistent with principles of exercise, motor learning & neuroplasticity literature • Designed to change behavior to promote maintenance •Not simply stimulating a transient behavior •Establishing lasting changes in neurophysiologic, motor-speech & internal sensori-motor systems (Fox et al., 2006) ………………..……………………………………………………………………………………………………………………………………..

Effects of LSVT on multiple systems • An example • What do you feel??

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Effects of LSVT on multiple systems • Appears to serve as a “trigger for distributed systemwide effects across the speech production system” (Fox et al., 2006)

• Beyond phonation, improvements have been noted in* •Articulation (transition duration, rate, extent) •Facial expression •Swallowing

*(See Fox et al., 2006 for specific study citations)

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LSVT in persons without PD • Several published studies have shown successful application of LSVT to select individuals with the following diagnoses (& different types of dysarthria): •Cerebellar ataxia (Sapir et al., 2003) •Multiple Sclerosis (Sapir et al., 2001) •Stroke (Wenke et al., 2008) •Traumatic Brain Injury (Wenke et al., 2008) •Aging Voice (Ramig et al., 2001) •Cerebral Palsy (Fox & Boliek, 2012) •Down’s Syndrome (Ramig & Fox, 2010) ………………..……………………………………………………………………………………………………………………………………..

Our study: LSVT in pediatric ABI 1. Determine the impact of LSVT on loudness, rate and perceptual measures of speech & communicative ability for adolescents with Acquired Childhood Dysarthria (ACD) secondary to Acquired Brain Injury (ABI) 2. Determine the degree to which LSVT treatment effects are maintained 3-months after treatment for adolescents with ACD 3. Determine whether (trained v untrained) listeners prefer baseline, post-treatment or follow-up speech samples of participants ………………..……………………………………………………………………………………………………………………………………..

Acquired childhood dysarthria (ACD) • • • •

Chronic condition associated with some acute change No specific evidence base for this disorder Assess and treat like adult dysarthria? Chronic ACD can have negative impacts on school performance and quality of life

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Why might LSVT work in ACD? • Single treatment target • Simple therapeutic goal • Particularly appropriate for younger persons & those with cognitive challenges following ABI

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Methods: Inclusion criteria • Over age 12 • Chronic ACD secondary to ABI • At least 6 months post-injury

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Assessments • Perceptual, acoustic, quality-of-life measures during 3 assessment phases •Prior to treatment •Immediately post-treatment •3-month follow-up • Periodic probes during treatment (2 sessions per week)

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Probe Sentences • Randomly chosen from the Assessment of Intelligibility of Dysarthric Speech (AssIDS) • Sentences of varying length •2 each •10, 11, 12, 13, 14 word sentences • Record loudness (dB SPL) and rate (total seconds for 10 probe sentences) ………………..……………………………………………………………………………………………………………………………………..

Subject 1 (S01) • • • • •

19-year-old male 3.5 years post-injury TBI Flaccid Dysarthria Fast rate, low volume, imprecise articulation

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Subject 2 (S02) • 13-year-old male • 2 years post-injury • Posterior fossa tumor resection • Spastic-Flaccid-Ataxic Dysarthria • Pitch breaks, monotone, slow rate, strained/strangled vocal quality ………………..……………………………………………………………………………………………………………………………………..

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Results • Loudness • Rate

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Results • Self Perceptual Ratings • Parent Perceptual Ratings

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Naturalness – what is it? • Speech variable affecting speaker’s conversational abilities • Related factors (Tamplin et al., 2008, Dagenais et al., 1998, 1999) •vocal intensity •vocal stress •pitch range •rate of speech •articulatory precision •prosody •intelligibility ………………..……………………………………………………………………………………………………………………………………..

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Naturalness – why does it matter? • Perceptual measure of speech affecting listeners’ reaction to speaker • Naturalness correlated with speaking ability (Dagenais et al., 2006)

• Not traditionally targeted in most speech therapies

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Methods re: listener sessions • 2 speakers, 16 sentence pairs each •Sentences randomly chosen and paired from pretreatment, post-treatment, and follow-up sessions •8 sentences rated for naturalness •8 sentences rated for intelligibility • 3 groups of listeners, ~20 each (Dagenais et al. 2006) •Experienced speech-language pathologists •Second-year graduate students •Naïve listeners ………………..……………………………………………………………………………………………………………………………………..

Why Three Groups? • Social attitudes are under-examined contextual factor when assessing functioning and disability outcomes as laid out by ICF (Brunnegard et al., 2009) •“Ratings provided by professionals do not necessarily reflect the attitudes of the community with whom the impaired speakers normally associate” (Dagenais et al., 2006)

• Attitudes may be affected by training, experience with the population in question (Liss, 2007)

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Listener Outcomes • By group • By subject

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Implications

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Conclusions • Results from individual treatment sessions were not overwhelming • Results from listener sessions • Appropriate for further investigation

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Limitations & Future Directions • Extent of cognitive and behavioral impairment • Time post-injury • Limited insight/awareness into speech impairments

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References Brunnegard, K., Lohmander, A., & van Doorn, J. (2009). Untrained listeners' ratings of speech disorders in a group with cleft palate: a comparison with speech and language pathologists' ratings. International Journal of Language & Communication Disorders 44(5), 656-674. Dagenais, P., Garcia, J., & Watts, C. (1998). Acceptability and intelligibility of mildly dysarthric speech by different listeners. In M.P. Cannito, K.M. Yorkston, & D.R. Beukelman (eds.), Neuromotor Speech Disorders: Nature, Assessment, and Treatment. Baltimore, MD: Brookes Publishing Co. Dagenais, P., Watts, C., Turnage, L., & Kennedy, S. (1999). Intelligibility and acceptability of moderately dysarthric speech by three types of listeners. Journal of Medical Speech Language Pathology 7: 91-96. Dagenais, P., Brown, G., & Moore, R. (2006). Speech rate effects upon intelligibility and acceptability of dysarthric speech. Clinical Linguistics & Phonetics 20(2/3): 141-148. Fox, C.M., & Boliek, C.A. (2012). Intensive voice treatment (LSVT LOUD) for children with spastic cerebral palsy and dysarthria. Journal of Speech, Language, and Hearing Research, 55(3), 930–45. Fox, C.M., Ramig, L.O., Ciucci, M.R., Sapir, S., McFarland, D.H., &Farley, B.G. (2006).The science and practice of LSVT/LOUD: Neural plasticity-principled approach to treating individuals with parkinson disease and other neurological disorders.” Seminars in Speech and Language, 27(4), 283–99. Liss, J. (2007). Perception of dysarthric speech. In G. Weismer (ed.). Motor Speech Disorders: Essays for Ray Kent. San Diego: Plural Publishing, 187-219.

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References Morgan, A.T. & Vogel, A.P. (2009). A cochrane review of treatment for dysarthria following acquired brain injury in children and adolescents. European Journal of Physical and Rehabilitation Medicine, 45(2), 197204. Ramig, L., Gray, S., Baker, K. et al. (2001). The aging voice: A review, treatment data and familial and genetic perspectives. Folia Phoniatrica et Logopaedica, 53(5), 252-265. Ramig, L. & Fox, C. (2010). LSVT LOUD training and certification workshop: A learning management system. Funded by Davis Phinney Foundation for Parkinson Disease and LSVT Global, www.LSVTGlobal.com (website). Sapir, S., Spielman, J., Ramig, L.O., Hinds, S.L., Countryman,S., Fox, C. & Story, B. (2003). Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on ataxic dysarthria: A case study.” American Journal of Speech-Language Pathology,12(4), 387–99. Tamplin, J. (2008). A pilot study into the effect of vocal exercises and singing on dysarthric speech. Neurorehabilitation 23: 207-216. Wenke, R.J., Theodoros, D. & Cornwell, P. (2008). The short- and long-term effectiveness of the LSVT for dysarthria following TBI and stroke. Brain Injury, 22(4), 339–52.

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Please contact me with questions or comments Jennifer Lundine Nationwide Children’s Hospital Ph: 614.722.8633 Email: [email protected]

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