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Emily Kosciulek

on 18 October 2012

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Transcript of LSVT

Lee Silverman
Voice Treatment
(LSVT) Bridget Keegan and Emily Kosciulek What is LSVT? LSVT is an intensive, structured treatment for individuals with Parkinson’s Disease and other neurological disorders. reduced loudness that may result in a soft tone that is monotone and monopitch
Due to reduced breath support and reduced movement of larynx
problem in sensory perception of amplitude that prevents a person from accurately monitoring his/her own voice.
Many speakers report feeling that their speech is loud and intelligible, indicating abnormal sensory processing.
patient’s have difficulty “independently generating (internal cueing/scaling) the right amount of effort to produce adequate loudness” (Fox 2012). Physical Pathologies of Parkinson’s disease Addressed by LSVT 90% of individuals with PD have speech and voice disorders. Patients with PD may have breathy phonation, hoarseness, reduced loudness, reduced prosody, and imprecise articulation (Ramig 2001). LSVT does not focus on all of these symptoms. It specificially targets: This treatment approach was designed for individuals with PD, but other populations have benefitted as well
multiple sclerosis
cerebral palsy
traumatic brain injury
Down syndrome
ataxic dysarthria
aging voice
vocal fold paralysis
Who Else Can Benefit from this treatment? There are two componets of LSVT: LSVT LOUD and LSVT BIG.
LSVT LOUD focuses on the speech motor system
LSVT BIG addresses limb motor systems.

This presentation focuses on LVST LOUD. It is designed to improve intelligible communication by treating the underlying physical pathologies associated with the disorder. LSVT uses intensive, high effort treatment coupled with proprioceptive feedback and auditory-vocal self monitoring to improve self-perception of speech motor output (Ramig 2001).

The idea is that increasing vocal loudness will trigger improved vocal quality , articulation and intonation, as well as a reduce rate of speech (Fox 2012).

LSVT therapy is based on these concepts :
Voice Loudness
High Effort to overcome rigidity and hypokinesia
Intensive Treatment
Quantification Components of Therapy Components of Therapy: Voice Loudness
During treatment, focus on …
increase fundamental frequency range
increase maximum duration of phonation

it is recommended to use Visipitch for data collecting

Therapy is administered on an intensive schedule of 4 days a week, 60 minutes a day, for 4 weeks.

Patients are expected to complete 1-2 hours of homework per night.

Therapy involves...
Repetition of tasks (minimum 15 repetitions)
saliency of treatment tasks
tasks to directly target bradykinesia/hypokinesia
direct translation of therapy exercises into functional daily activities
Components of Therapy: High Effort and Intensity the patient understands and accepts the amount of effort necessary to increase vocal loudness to normal limits
the main hurdle here is convincing the patient that a strong voice is a normal voice
most patients with Parkinson’s disease believe that their voice is at a normal level, although it is actually much softer than a normal voice

patients need to work on improving their sensory feedback in order to correct their perception of their vocal loudness Components of Therapy: Calibration motivate patient by providing feedback and document efficacy Components of Therapy: Quantification Short Term Goals
Tasks progress in difficulty over the 4 Weeks
Speech hierarchy in which utterance length and complexity increases over the 4 week period

Week 1: Words
Week 2: Phrases
Week 3: Reading aloud
Week 4: Conversations

(Spielman 2007) Hierarchy Maintain loud voice for longer periods of time and increase complexity of tasks (Fox 2012) LSVT improves respiratory drive, vocal loudness, and vocal fold abduction
Parkinson’s disease experienced increased subglottal air pressure, increase lung volume, increase sustained vowel phonation, increase maximum fundamental frequency range, and improvements in vocal fold adduction (Kleinow 2001).
"Several acoustis, aerodynamic, stroboscopic, EGG, and perceptual studies have demonstrated significant improvement in glottic closure, vocal fold vibratory movements, SPL, fundamental frequency, voice quality, and speech intelligbility after LSVT" (Ramig 2001)
training in vocal loudness resulted in statistically significant and lasting increases in sound pressure level (Fox 2012).
increased movement of the rib cage during speech breathing, increased subglottal air pressure, and improved closure and larger/more symmetrical movements of the vocal folds (Fox 2012).
A study done on 45 people with Parkinson’s disease found that the sound pressure levels increased from 8-13 dB after treatment (Trail 2005).
People who participated in LSVT showed improvements in vocal fold closure, as measured by a videostroboscopy and electroglottography (Trail 2005). Empirical Evidence Evidence shows tht LSVT improves articulatory movements

The frequent, intensive practice and repetition of LSVT generates other changes in speech production, including improvements in voice quality, speech intelligibility, and articulation (Spielman).
PET scans following LSVT training show an increase in basal ganglia activation and reduced levels of abnormal cortical activation. Proof that motor systems become more activated after LSVT training, aiding in the prodution of vowels (Spielman)
data has found improvemens in orofacial movements and tongue strength (Fox 2012)
LSVT training resulted in improvement in sound production levels and articulatory function (Ramig 1995) Empirical Evidence
15 repetitions of sustained "ah" for as long as possible
15 repetitions of sustained "ah" gliding up
15 repetiton of sustained "ah" gliding down
practice 10 functional sentences the patient uses in everyday life (e.g. "Good morning")
5 repetitions of the list

work on increasing the amplitude
increase complexity of the tasks based on the treatment hierarchy Treatment Session Outlines Positive Features:
It is not a cognitively demanding treatment.
Widespread benefits
New research shows consistent improvement in dysphagia in these populations by improving range of motion and vocal fold closure. (Even when you are targeting voice).
The frequent and intensive practice involved in LSVT treatment can also help with facial expression, articulation, swallowing, and neural function due to neural coupling (Spielman 2007).
“In addition to increasing vocal loudness levels for daily communication, there is evidence that the frequent, intensive practice and repetition of LSVT generate other changes in speech production, including improvements in voice quality, speech intelligibility, and articulation and promote positive changes to nonverbal behaviors, such as facial expression” (Spielman 2007). Critique of Treatment and Evidence This treatment can only be performed by a speech-language pathologist who are specifically certified in LSVT.
However, clinicians can practice a modified form of LSVT, although there is no evidence at this time examining the effectiveness of this
It is a time consuming treatment that involves dedication.
Most research has been done only on idiopathic PD in case study or small group research design
No evidence of effect of LSVT on those with atypical Parkinson’s or on large population samples
More studies should be done on assessing the opimal amount of time for treatment-is 4 weeks enough?
More studies on long-term effects and maintenance are needed Critique of Treatment and Evidence Fox, Cynthia. Eberbach, Georg. Ramig, Lorraine. Sapir, Shimon. (2012). LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinson's Disease Volume 2012, Article ID 391946, 12 pages.

Two randomized controlled trial (RCT) studies have been conducted. Data have documented that training increased vocal loudness results in a statistically significant and lasting increase in vocal sound pressure level (SPL) and frequency variability during speech (i.e., uncued conversational speech) as compared to a matched treatment focusing on training increased respiratory support. Effect size data for the primary outcome variable of vocal SPL in conversational speech were highly significant immediately posttreatment, and were maintained at 24 months posttreatment. Annotated Bibliography Sapir, S., Spielman, J., Ramig, L., Story, B. & Fox, S. (2007). Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson’s disease: Acoustic and perceptual findings. Journal of Speech, Language, and Hearing Research, 50, 899-912. Annotated Bibliography Ramig, L., Sapir, S., Countryman, S., Pawlas, A., O’Brien, C., Hoehn, M. & Thompson, L. (2001). Intensive voice treatment for patients with Parkinson’s disease: a 2 year follow up. Journal of Neurology, Neursurgery, and Psychiatry, 71, 493-498.

In this article, Ramig et al. assessed the long term (24 months) effects of the Lee Silverman voice treatment. One group received the LSVT®, which emphasises high phonatory-respiratory effort. The other group received respiratory therapy (RET), which emphasises high respiratory effort alone. The LSVT was significantly more effective than the RET in improving (increasing) SPL and STSD immediately post-treatment and maintaining those improvements at 2 year follow up. The findings provide evidence for the efficacy of the LSVT® as well as the long term maintenance of these effects in the treatment of voice and speech disorders in patients with idiopathic Parkinson's disease. In this article, researchers studied how LSVT can be used to improve speech clarity. They examined changes in speech clarity by measuring the first and second formants of the vowels /i/, /u/, and /a/ as well as using perceptual vowel ratings. The findings support previous findings that intensive treatments like LSVT helps to improve orofacial, respiratory, and laryngeal functions. Spielman J., Ramig L., Mahler, L., Halpern, A. & Gavin, W. (2007). Effects of an extended version of the Lee Silverman Voice Treatment on voice and speech in Parkinson’s Disease.
America Journal of Speech-Language Pathology, 16, 95-107.

This article used an extended version of the Lee Silverman Voice Therapy on patients with idiopathic Parkinson’s disease to examine the effects of the treatment on vocal SPL as well as determining if treatment dosages can be altered without changing the effect of the treatment. The researchers found that the dB SPL increased by 8 dB after treatment and maintained increased vocal SPL by 7.2 dB at six months. The authors concluded that using an extended form of the LSVT treatment yielded consistent results as the regular form. More research needs to be conducted on the efficacy of an extended form of LSVT. Trail, M., Fox, C., Ramig, L., Sapir, S., Howard, J. & Lai, E. (2005). Speech treatment for Parkinson’s disease. Neuro Rehabilitation, 20, 205-221. Annotated Bibliography This article reviewed current literature on the characteristics and features of voice disorders in individuals with Parkinson’s disease and reviewed the treatments available for treatment, including medical and surgical treatments as well as behavioral speech-language pathology. They concluded that the most common perceptual speech characteristics are reduced loudness, monotone, monopitch, hoarse voice, and imprecise articulation. Lee Silverman Voice Therapy is an intensive voice therapy that focuses on voice, improving sensory perception of loudness, intensity and high-effort treatment style. When paired with behavioral speech therapy, LSVT appears to be the most effective type of intervention for individuals with Parkinson’s disease. Brooks Rehabilitation. (2012). Lee Silverman Voice Treatment (LSVT Loud). In Brooks Rehabilitation. Retrieved October 1, 2012, from http://www.brookshealth.org/outpatient/locations/orangepark/LSVT/.

undefined. (n.d.). LSVT Loud. In LSVT Global. Retrieved October 1, 2012, from http://www.lsvtglobal.com/.

undefined. (2011). Lee Silverman Voice Treatment. In Courage Center. Retrieved October 1, 2012, from http://www.couragecenter.org/ContentPages/lsvt.aspx. Before and After Therapy Example The patient will independently produce pitch glides at an average volume of 70 dB with 80% accuracy.

The patient will independently produce functional words (3-4 syllables) at an average volume of 70 dB with 80% accuracy.

The patient will independently produce functional phrases (3-4 syllables at an average volume of 70dB with 80% accuracy.

The patient will independently produce functional sentences (8-10 syllables at an average volume of 70dB with 80% accuracy.

First Half of Treatment Session (30 minutes)
Second Half of Treatment Session (30 minutes): (Fox 2012) PD patients are stuck in a cycle of being soft and small (Fox 2012) "Increasing vocal loudness will increase vocal fold adduction and increase larygneal muscle activation to create a more efficient phonatory system" (Ramig 2001)

“A simple, redundant and intensive treatment may help accommodate the processing speed, memory, and executive function deficits observed in some individuals with PD, and promote overlearning and internalization of the vocal effort required for normal loudness (Trail 2005).

Over learning a new motor task through intensive practice and repetition has the potential to improve task automaticity, decrease the perception of effort required to perform the task, and create a stronger memory (habit) for the motor behavior” (Spielman 2007).

"Intensive, high-effort treatment of vocal functions… should help those with Parkinson's disease to rescale the magnitude of their speech motor output and habituate to this level in conversation" (Ramig 2001) Therapy Rationale
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