good morning everyone it's good to see such a big crowd can you guys hear me okay trying not to talk too loud because I know he's going to amplify me all right so before we get started I just want to let everyone know if you need the restroom during my presentation it's right down the hall past the front desk you're welcome to leave whenever you need to um so just to introduce myself my name is Emily Bishop I'm a speech language pathologist with a hospital with Novant Health but I primarily work in outpatient so I'm over at Novant rehab center on Oleander it used to be called Oleander rehab for any of those who are familiar with that so at any time during my presentation you guys can stop and ask questions or if you have any comments you want to make I'm totally okay with that um and today I was told to kind of just give you guys a little insight into what speech language pathology is and how it relates to Parkinson's so that's my goal for today any questions about me before I get started it works speech therapy good that's awesome where have you been if you don't mind me sharing to okay very good awesome come on yeah what'd you say okay good that's great great all right so we will get started okay so I'm gonna start by just filling you in on what a speech language pathologist is we're also called Speech therapists speech language pathologist is our fancy name um so as a speech language pathologist we work to prevent assess diagnose and treat speech language social communication cognitive communication and swallowing disorders in children and adults so today my goal is to focus on the areas that we primarily see related to Parkinson's there are other areas as you see that we work on but I'm going to dive deeper into the ones that we see mostly with Parkinson's so my first um I also wanted to go into where speech language Pathologists work so you guys know the different options you guys have for therapy if you ever want to pursue speech therapy um the first place is obviously hospitals I work for a hospital so you can receive speech therapy while you're in the hospital like in acute care if you need it there's a rehab hospital with Novant as well the Inpatient Rehab Hospital where I work as well some just part-time and then of course in outpatient so there's outpatient clinics or private practices just like doctors offices skill nursing facilities or nursing homes VA clinics Home Health which is where therapists or skilled nursing comes into your home to provide therapy or treatment colleges and universities so their speech language Pathologists at universities who help people like me that was in grad school teach us how to be a speech therapist or in a research setting doing research and then also we work in schools and daycares all right so my first area I want to go into today is related to swallowing so um our fancy word for any disorders of swallowing or difficulties with swallowing is dysphagia or dysphagia some people say there's three stages to swallowing there's the oral phase the pharyngeal phase and the esophageal phase so the oral phase to go into more detail about that is related to the mouth so we're looking for patient's ability to have good lip closure so being able to close their lips when they're chewing and moving food around so that nothing's spilling out we're also looking at tongue control and movement and then we're looking at mastication mastication is our fancy word for chewing how well people are able to chew their food and control it in the mouth and then we're looking for after the swallow after someone swallows if there's a lot of residue left in their mouth if there's a lot of food still hanging out in their mouth so that's kind of the oral phase and what speech language Pathologists look for with the oral phase and then the pharyngeal phase is your pharynx is also known as your throat so that's the part where we're going in and looking at your throat and what's happening there so with that phase we're looking at the initiation of the swallow and how quickly your body is protecting your Airway during that swallow so I'll go into the anatomy a little bit more in a second so you can kind of see how that works and I also have a video of of a typical swallow um but the most important thing the most important thing is that our Airway is protected when we're swallowing otherwise we're going to have that sensation of coughing or choking when we swallow um so we're also looking at soft palate elevation and I'm gonna kind of try to point to this over here I know it's hard to see um so I don't have to get closer um trying to point at the it's going crazy I know I'm just trying to point at that diagram okay that's all right no um the diagram where it says the soft palate kind of it's up at the top it's the pink structure kind of behind the yellow yep so it's hard to see on there but um that the soft palate that closes off when you swallow it raises up and that closes off your nasal cavity so if you've ever had liquid or food kind of spill out your nose or come back up um that soft palate's probably not working like it should so that's one thing we look at with the swallow and then we're also looking at laryngeal elevation so your larynx is also known as your voice box or your Adam's Apple area um when you swallow that moves up and forward to open up the back of your throat for everything to spill into the correct tube so to speak when you're swallowing um but it also closes off your Airway too so that's important there's a lot of things we're looking at that are very technical with the pharyngeal phase of swallowing but these are just some things and then we also look at the muscles in the throat and their strength to be able to contract and push down food as you're swallowing so um our goal with swallowing is to look at if there's any weaknesses with the oral or pharyngeal phase and then we're also checking to see if aspiration occurs so if you've ever heard of the word aspiration that means food or liquid entering your Airway which we obviously do not want that to happen because if that happens consistently it can lead to pneumonia so that's usually one of the biggest concerns that Physicians or doctors have is um with especially with Parkinson's is okay are we coughing a lot when we're eating or drinking why is that happening we they usually send you to a speech therapist to assess that because we don't want you to have pneumonia um and then the esophageal phase so we look at the very top of the esophagus with swallowing but we cannot um treat or diagnose anything with it that would be a gastrointestinal doctor so a GI physician would be the ones we would typically refer you to if we feel like the the issues are coming related to the esophageal phase okay so next I have a little video if we can get it to work and this just looks at what a normal swallow looks like [Music] this side view of the head highlight structures involved with swallowing that includes the tongue teeth epiglottis and esophagus the teeth grind and chop food into tiny pieces while the glands in the mouth moisten it with saliva then the tongue pushes the moistened food or bolus to the back of the throat and down into the esophagus which leads to the stomach let's watch the swallowing process again first the tongue pushes the food into the throat foreign next the epiglottis a small but important flap of tissue folds over the voice box at the top of the windpipe this keeps food from going down the wrong way finally the esophagus contracts and moves food towards the stomach excuse me whoever created this video had quite an imagination laughs okay so our next slide we're going to go into talks about assessment so what we as speech language Pathologists do to assess for these things so that we can then provide treatment for you guys so our first thing we have is a clinical swallow evaluation the purpose of that is to determine the presence or absence of signs and symptoms of dysphagia with consideration for factors like fatigue during meals posturing or positioning and environmental conditions um this exam gives us an idea of whether we need to pursue an instrumental assessment so typically a clinical swallow evaluation for me looks like I go through your case history what's been going on any of your medical diagnoses and then we talk about your signs and symptoms you may be having and then I will have you eat and drink different consistencies so I usually give you what we call a thin liquid which is just water juice something like that that's real thin and watery and then I have you eat a puree or pudding consistency so applesauce or pudding and then I would have you eat a soft consistency so it's usually like a muffin A Little Debbie cake a nutrigrain bar or something that's kind of soft and then I skip to a regular solid so typically in our Clinic like I said I work in outpatient for the regular solid what we typically have is like a cracker so it's going to be a graham cracker or something that's dry crunchy flaky sometimes that's harder for the body to handle so that's what a clinical swallow evaluation looks like I would have you eat and drink those things and I'm just going to watch you I'm going to feel your throat to feel for laryngeal elevation that Adam's apple or voice box moving up and forward I'm going to look at how you chew what's left in your mouth after you swallow and determine if we need to get an instrumental assessment most of the time and really lately our field has really been pushing for those instrumental assessments right off the bat so and that's what I would recommend to but if you're unsure whether you need to pursue one of those typically your doctor will send you to us first to just have this clinical swallow evaluation and then we'll say yeah we probably need to do an instrumental assessment to see what's physically going on with inside so those are what I'm going to go into next we've got two instrumental assessments one is called a modified barium swallow study or a video study and then we've got a fees which stands for fiber optic or flexible endoscopic evaluation of swallowing both tests are great there's not usually a there's not one that's better than the other it just kind of depends on the patient what they're comfortable with and what we need to assess so I'm going to start by talking about the modified barium swallow study have any of you guys had any of these procedures done yeah good okay awesome so a modified barium swallow study is a radiographic procedure that provides a direct Dynamic view of the oral pharyngeal and upper esophageal functions so this is an X-ray test here with the hospital we have obviously in the hospital they can do these tests but also in outpatient they um they do them over at the medical mall or medical plaza I think it's called now but it's just an X-ray test and it's done with a speech-language pathologist and usually a radiologist or Radiology PA um those are the two people in the room looking at your swallowing so this is this test is beneficial for identifying whether aspiration has occurred again there's my word um aspiration means things going into your Airway um and then it also looks at any weaknesses within the throat or where breakdowns are occurring so that as speech pathologists we know what we need to work on um let's see that's kind of the biggest takeaway um it looks like the clinical swallow evaluation they would have you eat and drink similar things to what I mentioned earlier but you're going to have a little bit of barium on it it's not a ton of barium just a little bit and that's what allows them to actually see it going down any questions about that procedure right now okay typically reasons we would not do that test would be if a patient has a hard time maintaining an upright position we do have to put you in a little x-ray machine um so that's really the only thing that would keep someone from having that or if they have an allergy to Barium that would be the only other thing and on the next slide I have pictures of both of these tests so you'll be able to see kind of what it looks like um and then the next one I want to talk about is the fees or the fiber optic endoscopic evaluation of swallowing so with this procedure it's a small flexible tube that's inserted through the nose allowing visualization of the inside of the throat so it's a little scope if you guys have ever been scoped by an ENT an ear nose and throat doctor um it's a little bit different than that because we're putting that scope in there with just a little bit of lubricant on the end to help it slide through your nose and then we're holding that scope there while you eat and drink so we can see what's happening now most people were like I don't know about that I don't really want something in my nose but I will be honest with you I when we were training to be able to do this test um I had it done like 15 times in a row to myself by people learning how to do it and it really wasn't that bad uh it's a little uncomfortable you know something in your nose is uncomfortable but we try to stay in the lowest um nasal cavity to get to your throat so we're not going super high up um and so it's it's really not as bad as it may sound but um so anyways with this test what we're doing is putting that tube in your nose and sitting at the top of your throat so the camera is looking down into your throat we're going above it looking down in there um and this will display on a computer screen so if you're comfortable and you're not a queasy person you can watch your swallowing on that screen while we're doing the test which actually gives us really good feedback on what's Happening yes sir vision isn't it always sprayed your extensions in other words so you can do it on the field as you know so that's a good point actually with speech therapists we do not do the spray because we don't want anything to be numb so it's not in case it doesn't work like it normally would because if we numb some of those structures things might not close off like they normally do now with an ENT they typically do the numbing spray because they're not looking at the swallow function they're looking at your vocal cords or just the anatomy at rest but yes that's a good point so we don't use the numbing spray typically or really ever it's just a little bit of lubricant on the end but we do offer this test in our Clinic over an outpatient which is kind of a perk of it you don't have to go to the medical mall or the hospital to have it done um the orders from your doctor come straight to us to do the test in our clinic and so that's nice that we don't have to go there um and so same thing with this test we're going to watch you eat and drink different consistencies foods and liquids this time it's with no barium it just we just put a little bit of food coloring in the food and drink to kind of see it down and differentiate between the food and liquid and your just saliva so we know what's what um the only contraindications for this test would be obviously if the patient's not comfortable doing that test we wouldn't do that one or if you have someone who has consistent nose bleeding if you have nosebleeds a lot we would probably skip this test because we don't want to make you have a nosebleed but out of the research shows that there's only a few like a small percentage of nosebleeds that actually occur with this test and when they do occur it's usually patients who have them frequently so it's usually not something we have to worry about even when I had it done to myself 15 times in a row my nose didn't even get a slight bit of blood so all right any other questions about that procedure and I can always come back to things later if you guys have any other questions all right so here you can see on the left side of the screen um that is the modified barium swallow study so that's the X-ray test as you can see there's kind of like we call it a c arm that swings in front of the on the side of you to get that sideways View and then there's a TV monitor on the side that the speech language pathologist and radiologist is looking at while you're swallowing now with the modified barium swallow study everything is a really quick picture because we're trying to reduce the amount of exposure you're getting to radiation so that's another you know thing with the fees versus the modified barium swallow study is the fees we can do that test for as long as we need to whereas the modified barium swallow it's going to be a really quick procedure because we don't want to expose you to a lot of radiation um so that's kind of what that looks like and then on the right is the fees that's the camera that goes through the nose that was actually a picture I took of two speech language Pathologists that I work with an outpatient um that was when we were doing our training course and they gave me permission to put their picture up there um so you can see what that little scope looks like it's a very very very thin tube and she's looking at the computer screen that's across from her all right so dysphagia treatment so dysphagia treatment this is the good stuff where we tell you what we can do to help so if on one of those instrumental tests we identify there's weaknesses somewhere between the mouth and the throat this is what we have to offer so we the first and foremost thing that we typically do are swallowing exercises there's a couple different ones and those exercises we provide based on where the weakness is in the throat or mouth so it's not like oh just do this exercise that'll help we prescribe them based on where the weakness is so that's why that instrumental assessment is really important um and then postural or position techniques so sounds like what it is um we can try we obviously want to try to have an upright position when we're eating and if we're not able to do that because of weakness or whatever um we'll try to figure out ways that will help kind of compensate for it so and then sometimes there can be different strategies you can do with your neck or head to help ease your swallowing so sometimes a chin tuck may help that's not always though some patients might have said oh my my friend or my doctor said just tuck your chin when you swallow that might help that's not always the case these are things we have to trial on our instrumental assessment to see if they actually help or work um and then obviously pacing and feeding techniques so sometimes there can be adaptations we can make to the way you eat to help ease Transit um electrical stimulation so there are electrodes that we have that sometimes we can put on the throat or the face to kind of give muscles the Boost that they need during the swallowing exercises that we prescribe now there are some contraindications to electrical stimulation um so before just signing up for that you would definitely want to talk to a speech therapist about those contraindications because sometimes um I know I've had patients with deep brain stimulators for Parkinson's and we would not do stem on that because we don't want to throw anything off off whack with the deep brain stimulator and then the next thing we would try would be diet modifications so if on the swallow test we saw someone had aspiration whether it was with liquids whether it was with solids we would probably recommend modifying your diet initially at least so that may mean sticking to softer Foods or kind of chopping up your Meats instead of just taking a big old bite of of chicken or steak then we would try sometimes with the liquids I feel like that's mostly what we see a hard time swallowing liquids we would suggest putting some thickener in the liquids because it helps to slow the transit and there's different brands and different types that we would recommend based on your swallow test but that's sometimes what we would try um in order to reduce the risk of aspiration and pneumonia occurring so um and then medical intervention we typically obviously cannot provide medical intervention but other physicians may do that whether it's some sort of surgery injections or just medications like for reflux like I was mentioning earlier yes sir yep that's a great question it depends on the patient but typically the barium swallow um is the actual tested itself itself is maybe like five to ten minutes and then the speech therapist usually spends time kind of educating you on what she saw he or she saw um and then the fees that camera the scope test is it can we can go for as long as we need to but I would say on average it's about 10 to 15 minutes so they're both short yes yes same thing we on all of them we try different consistencies to see what may be giving problems or not giving problems any other questions about treatment I know this is but yes sir so okay I will touch on that at the end how about that okay um yes so with dysphagia treatment I know this is just very like overview General I don't want to go into too many details but just kind of giving you an idea of what speech therapists can do and how we can if you want to go see one how what we have to offer all right so the next area I went into is speech so um our fancy word our medical term for speech disorders is dysarthria so dysarthria is defined as a group of neurogenic speech disorders characterized by abnormalities in the strength speed range steadiness tone or accuracy of movement required for breathing phonatory resonatory articulatory or prozotic aspects of speech production so that's a mouthful so let me break it down a little bit um so when you think of a speech therapist you think of just helping people talk right um but it's a lot more goes into that with the speech aspect so we're looking at when it says breathing we're looking at breast support are they able to breathe from their lower abdominal area diaphragm or are the breasts very short and coming from up here in the chest then we're looking at so we're working our way up from our lungs up to the mouth so we're looking at phonation phonation means voice the ability to create voice and how that voice sounds and then we're looking at the resonance which is how again how the voice sounds so sometimes patients may have um nasal air emission meaning like their their voice kind of comes out of their nose or something like that that would be resonance and we would look at why that's happening and how we can help with that and then obviously articulation so that's our word for how the lips teeth tongue jaw are moving to form the sounds and if that's accurate and then we're looking at prozotic aspects so prosody is inflection in um in intonation the ability to kind of create pitch changes in your voice or if it's just one flat prosody okay so I went specifically into hypokinetic dysarthria because that is the type of dysarthria that is typically seen with Parkinson's now it's not always the case but that's kind of the one that research has shown sticks out in those with Parkinson's disease so the speech characteristics for hypokinetic dysarthria include mono pitch pitch is being able to change the tone the inflection of your voice going from high from high to low so typically it's just kind of one flat pitch one loudness so it's difficult to increase loudness or reduce loudness um as I that's the next Point reduce loudness or stress tendency for Rapid or accelerated rate of speech so that just means your speech is really really fast and sometimes it can be hard to understand so we've got pacing techniques to try to help you slow that down um and then rapidly repeated phonemes sometimes that kind of just means like stuttering or disfluency of speech so sometimes that can happen at initiation of speech with Parkinson's or other neurological conditions too um and then I'm going to skip the Blurred amrs because that kind of goes hand in hand and then the physical characteristics are on the other side um those are just related to Parkinson's and typically what goes hand in hand with speech and the physical physical characteristics a lot of my information today comes from Asha which is the American speech hearing Association which is our governing body for speech therapists they provide us with a wealth of resources so a lot of what you're seeing today you're you can go and find on their website as well again that's Asha that's where I pretty much took this information for this slide from all right so for treatment options with dysarthria or speech disorders we've got restorative and compensatory approaches so the restorative approaches we're training the different speech subsystems focusing on respiration intelligibility and prosody like I was saying the different areas and ways to help strengthen those areas a lot of times it's through really focusing on breath support because that's one of the biggest things I've noticed that is hard to retrain we get so used to taking short little small breaths from up here but our power is really going to be coming from our diaphragm and from our belly when we breathe and then compensatory strategies are training to improve the comprehensibility of speech by focusing on use of communication strategies modifying the communication environment and using multimodal communication so modifying the communication environment would take education for both the patient and the caregiver on how we can and modify things within the environment so sometimes you know we're trying to communicate over the loud TV that's in the background or yelling across the house okay can we find ways to not do that or overcome that um and then multimodal communication that looks like using things other than just your voice and speech that's going to be using gestures facial expressions and we also have other devices um AAC devices which stands for augmentative alternative communication where we can use like Picture Exchange where we're using pictures for communication now typically when we would use that would be in a in a pretty severe situation where the patient is has lost the ability to communicate verbally and so there's different devices and companies that we work with that would help provide devices to kind of augment communication if it came to that all right any questions about speech right now okay let's move on all right so then we're going to go into voice so speech and voice kind of go hand in hand with Parkinson's um but specifically voice disorders are our medical word is dysphonia and dysphonia is defined as it occurs when the voice quality pitch and loudness differ are in or are inappropriate for an individual's age gender cultural background or geographic location so if you've ever had even right now I can feel my voice is changing from talking so much um so I'm going to actually take a sip of water okay so um you guys may have noticed some changes in your voice since you've been diagnosed with Parkinson's whether it's weaker not as loud not as strong or maybe hoarse too um those are things that speech therapists look at and can help with um and then I took the second definition which is hypophonia so phonia is stands for phonation um this just means kind of like dysfunction and then hypo means lacking or reduced so hypophonia stands for reduced vocal loudness and that's one of the key characteristics that we can see in Parkinson's um so I'm going to go into on the next slide more specific treatment about what there's a treatment designed specifically for patients with Parkinson's with that um I lied I'm going to talk about assessment first so assessment with voice we always want you to see an ENT or an otolaryngologist an ear nose and throat doctor because we want them to visualize the anatomy they're the experts on voice so they would be the ones to look at your Anatomy make sure there's nothing physiologically wrong before we would start any sort of voice therapy so they do the assessment then they refer you to us for treatment and assessment for speech therapy um so as a speech therapist our assessment looks at case history we're going to ask you questions about your history what's been going on how long that's been going on that kind of thing and then we would typically have you rate yourself rate your own voice there's different forms and patient rating scales that we have to give you that look at different qualities of the voice and it just gives us good information on how you rate your voice now so that when we're done with treatment you can kind of rate it again and see if you feel like there's been Improvement um and then we're going to assess respiration again which is breathing because that's really really important and then we're going to look at clinical acoustic measures of vocal quality so vocal quality we're going to look at roughness of The Voice breathiness strain pitch loudness Etc just the different qualities of voice yes sir absolutely so and I should have included this at the beginning when we take you guys back for assessment in our office it's different in the hospital setting but in outpatient we love for a caregiver or family member to come in and give their input as long as the patient's comfortable with it but that gives us a good idea because there may be things that the patients with Parkinson's may not identify or know is occurring that youth may be picked up on so yes absolutely all right okay so now we're going to talk about voice treatment so the biggest one you guys may have heard of it is lsvt loud so that stands for Lee Silverman voice treatment and the one related to speech therapist is lsvt loud specifically you may have heard of lsvt big that's um typically related to physical therapy and occupational therapy um but this is the one designed for speech therapy so lset it was named after Miss Lee Silverman she she was a sweet lady who had Parkinson's disease and her family kept saying I really wish I could just hear her and understand her I have the hardest time hearing her and her doctor actually went on to develop this whole treatment program based on her so the research began in around 1987 by Dr Lorraine ramig who has a PhD and she designed this program and it helps to train people with Parkinson's to use their voice at a more normal loudness level while speaking at home work or in the community so sometimes with Parkinson's there can be a mismatch between how you think you're talking and how you actually sound and why this happens not a hundred percent sure but the body re kind of calibrates to this normal setting of okay this loudness sounds normal but it may not be quite loud enough for average conversation yes sir yeah that's a good question there are voice um sound meters and that's what we use in our treatment with lsvt so usually lsvt is done or it needs to be done by a certified provider so I am certified in lsvt that's partially why they asked me to come speak today because you're not gonna we went through this extensive training and online education and practice to learn how to do it and implement it for you guys so um with part of the treatment is using a sound meter to level the measure the level of loudness during treatment so there's apps there's free apps online um on your phone I have one on my phone um you could just look up sound meter voice sound meter um now it's not going to probably be as accurate as like an actual device but it's close enough to wherever you're able to measure um so did you have lsvt or was it a different kind of different okay yeah yeah okay yes sir this one okay yes yep yes so that was the next point I was going to get into it's a very intensive treatment it's four times a week for four weeks so 16 sessions um and the reason that is is because it takes a long time to recalibrate to going from maybe this soft kind of monotone voice to being loud and projecting at a nice clear quality um and so the whole goal of it is to is about recalibrating the voice and speech um so the idea of this treatment is built on three key strategies so the first being vocal loudness that's our Target for the treatment program we're focusing on being loud thinking loud the entire time because the other things the other speech characteristics and voice characteristics will fall into place if we can focus on the loudness and the whole goal of the treatment is so the the speech therapist would model what we want you to do and then you would repeat it back to us and then as you get more independent we kind of fade our modeling and have you just do those exercises in your nice loud voice and we give you cues and hints here and there when you need it um so the goal is vocal loudness and then the mode or the intensity is the Intensive dosage with high effort we're putting a lot of effort in just like if you've ever gone to physical therapy they're working you hard they're making you really strengthen those muscles we're going to do the exact same thing with your breast support and the muscles within your throat for this treatment and then um our goal at the end and throughout is for generalization or calibration um and that just means we're recalibrating the sensory feedback so people recognize their new louder voices are within normal limits and this increases the likelihood that people with Parkinson's will feel comfortable with and use their louder voice at home work and play so a lot of times when we're getting started with treatment and you may be able to speak into this more than I have I've noticed patients say I just sound so loud when I'm doing this like it's so loud but it's actually not to the average listener we're listening for that loudness so that you can be understood by your friends and family so I know this is a very just generic overview I do have a video on the next slide that goes into kind of a testimonial from someone who had done lsvt and then I have a few handouts that I printed at home last night that's um kind of goes over lsvt again I'll give them to you guys after this um if anyone's interested in them or you can look their website up too um so any questions on that before we watch the brief video okay uh first met him you can't get past that yeah and as I was going through this I thought about him a lot and started to talk about it and he told me well my wife understands everything I'm saying I said Ah that's new in other words you are not involved in any other way because she will always understand sure that's horrible but I have known as too far to developing our friendship further and broadening them then we will speak out and my brother and partners is also the same thing yeah my brother has Therapies so anyway the point is family has to kind of respond we say four hours before you use this kind of thing yeah otherwise they just didn't realize right because they may not be aware that their voices is too soft exactly my mother had her Farms and that caught them right yeah that's great great information yes ma'am um um Jim had the lsvt maybe four years ago nobody here was doing it so is it new that you guys are doing um maybe so yeah [Music] okay and um I'm wondering do you would Medicare pay for it again yeah they would I think so yep I mean I can't make any promises but usually Medicare as long as we can justify medical necessity and to me being able to communicate with your friends and family is a medical necessity so um as long as we can justify that yes yes um foreign it used to be called Oleander rehab right by Jungle Rapids if you're familiar with where that is we have physical therapy occupational therapy and speech therapy there um I am trained in lsvt as well as one other speech therapist there so we offer it there I to my knowledge I'm not aware of any other like private practices that have trained clinicians there may be but I just am not aware of it um so yes yes it does it uh hiring referral you know just the speech therapy referral yeah so your primary care your neurologist whoever can I'm sure they would be happy to refer you to speech therapy yep yep yes ma'am do you want to speak just for a minute to the difference between lsdt loud and the um speak out I just hope that was the speaker on that a few I don't know a while ago at one of our meetings and uh Jim saxophone but I'd be curious to what what you would say about the difference yeah I'm going to be honest I don't know a lot about speak out because I'm not I did not do any training for that um I did the lsvt loud so you may actually know more than I do about it and I'd love to hear your input but I think the goal with speak out is not as intensive as lsvt um and so from what I hear it's kind of harder to carry that over and make generalize it to to daily life but other than that I'm not fully sure if if you guys have experience on what you've noticed I'd love to know other therapy Queen I I'm sure that's stupid to both of them exactly that's yeah and that yeah I will be honest you may go through lsvt and then a couple months later your family members are saying wow you're really quiet again but the idea even after you're done every single day you're supposed to keep doing those lsdt exercises at least for 10 to 15 minutes um and then you know if you need to kind of like check back in with a speech therapist here and there like you know once a year or something then that's okay too and that insurance would would cover that as well Medicare yeah yeah yes sir I did this over the internet yeah okay and it turned out that to schedule as much as you could squeeze in four a week for a long time to see all three therapists now this taught me a while because each one had a very different approach to the same okay um they have to be I'm suggesting from my perspective from my personality you have to be a bit aggressive and insist insist straight down to my last personal visit up there and see the Odell wound offices yes the therapists jumped out of the world and created me and I said something she said what because she just said you'll remember this when you really had problems [Music] to that but right now I can tell I'm doing okay but I tend to fall back from the talk we can never have a resume I think you're probably going to be able to start cheers you know if your regular boys you're here let's do it apart companies you got to pick it up two notches or whatever it's going to sell out to you it's not really yes yes great yes sir the program is on the computer that you have for vocal projection as well as for uh dictation so you can set the loudness in those things and I'm wondering about you to do something like that on their computer where you could have your wife listen to that particular level and then determine turn it on the computer and you can hear it barely hear it you know yeah this is about so we just talked that my yeah absolutely that's great input for sure all right it sounds a lot louder than having urine needs yes yes for sure all right well I'm gonna move on I can I'll be happy to talk to anybody else you know one-on-one if you would like to talk about lsvt um I just know we're gonna break out in a few minutes to do our breakout sessions so um let's play the video if we're able to just a testimonial about lsvt yes yes thank you when we met you hadn't had any treatment before none at all so tell me a little bit about before we started lsvt loud treatment what you were noticing what other people were noticing with your voice and speech I was working then with the fire department and uh it was important for me to communicate I was the the chief of the department had the board of directors meetings and a lot of communications with the firefighters and command officers and begin to notice as well with the physical limitations that we're developing my voice seemed to be softening I didn't pay a lot of attention to it but the firefighters would say huh okay could you repeat that didn't catch that and uh so we were spending a lot of time rehashing things that had already been said do you remember when we first started doing lsvt where you started to get that awareness that oh it's my voice it's too quiet in your office this is where it happened at the first sessions of awe you kept telling me no let's get a strong uh louder and I'd go geez that's pretty loud it felt loud to me but you kept driving it further and further you got to be louder and louder and the exercises and then I started to notice that there was a difference that sometimes I'd be loud and sometimes I wouldn't be so loud and I was starting to pick up on the differences because I wasn't maintaining consistency with my loud voice which your sessions uh really trained consistency into me that this is a life experience change that the exercises work and it will build your confidence it will help you to succeed where we have difficulties physically succeeding this is something you can capture this is not a difficult program but it's a program that continually reminds us of what our voice can be please don't stop we're going to whip this someday I just think he's the cutest man all right so that kind of when I was a student I write long essays that about cognition and cognitive communication so really quickly I'm gonna just cover that so as speech language Pathologists yes we also work on cognition um now we also neuropsychologists also would kind of be the ones to diagnose and have different areas within cognition that they find maybe are stronger or some that are a little bit harder um and then they may send you to us for treatment but treatment typically looks like um using compensatory memory strategies so we'd give you some strategies of how to kind of help support memory um and then wherever else when we do our assessment whether it's attention executive function problem solving those areas if we pick up on that there's some areas lacking with that then we would do just different activities in therapy that kind of simulate that and develop goals based on what you want to get back to and what's difficult for you on then we would just do activities and treatment tasks to kind of simulate those things and practice them with cues so that hopefully with with repetition um things would improve that's kind of the gist of it did you have any specific questions about cognitive communication um and the difficulty a lot of times you can't find not a matter of speaking the word a matter of what is the world supposed to be saying that I can't say yeah because the disability of not being able to search and find them yeah I think Mrs graysberg when he's already got the word that you want to say but actually getting to the step before that I don't know it's much harder okay yeah that's a good point you brought up too so being word finding being able to find the words you want to use sometimes it'll be kind of on the tip of your tongue or it might not be there at all and you're just having to search in your brain for that word that is another area that speech-language Pathologists can work on it's more of the language centers of the brain um and there's just different strategies word finding strategies that we have to offer and practice going through those strategies to kind of help you retrieve those words or education to your family and caregivers on how they can help you with that too that's kind of the gist of of what therapy would look like for sure with that same schedule no no no no um it would just depend on what we felt you needed um whether it's one time a week twice a week follow up once every other week it's not as intensive as the lsvt no unless we felt like we needed it all right any other questions comments concerns for me I'm happy to talk to anyone else on an individual basis if you'd like I know we've got it scheduled to break out and to groups any other questions okay is there someone here that's facilitating the different groups oh good okay awesome thank you thank you thank you guys