1. Lee Silverman Voice Treatment (LSVT®)
Presented by:
Andrea Bossuyt
4/1/2003

2. LSVT® Foundation LSVT® founder: Lorraine Olson Ramig, Ph.D., CCC-SLP
Professor, University of Colorado-Boulder
Research Associate, Wilbur James Gould
Voice Research Center, Denver, Colorado

3. What is the LSVT® Foundation?
A Colorado non-profit organization dedicated to improving communication for those with a neurological disorder
With a specialty is in Parkinson disease
Holds a certification mark /®/ to insure the quality and standard of the foundation

4. LSVT® Foundation Goals
Training and updating clinicians in the LSVT®
Educating other health care professionals about the importance of LSVT® and the positive outcomes
Providing information services, such the LSVT clinician referral database, patient and clinician newsletter, listserves, and web pages

5. Parkinson Disease
Affects approximately 10% of Americans over the age of 60.
75-100% also develop speech and voice problems (Kleinow et al, 2001)
“…is a generative, progressive disease of the basal ganglia, manifesting itself in a hypokinetic dysarthria, nonintention tremor (at-rest tremor), with sluggish intonation of motor movements (such as gait).
Hypokinetic Dysarthria
Reduced loudness
Breathy voice
Monotony of pitch
Intermittent rapid rushes of speech
Soft production of consonants
(Boone & MacFarlane, 2000)

6. Voice Therapy for Parkinson Disease?
Significant respiratory difficulties and bowed vocal folds have been reported as causes of voice symptoms in those with Parkinson disease
The most effective approach has been to exaggerate one component of speech to improve all other components (e.g. loudness, voice, quality, pitch, rate)
These observations has been formalized into the LSVT®
Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor stability in IPD: effects of rate and loudness manipulations. Journal of Speech, Language, and Hearing Research, 44,

7. LSVT® Program
1st speech treatment with short and long-term efficacy data documenting increased functional communication
Research has been supported by the National Institutes of Health (NIH) and the National Institute for Deafness and other Communication Disorders (NIDCD)

8. LSVT® Program The program incorporates:
Enhancing the vocal source (adduction)
Using phonation as a trigger to increase effort and coordination through stimulating the “loud” global variable (respiratory support)
Retraining sensory processing during the speech production (increasing fundamental frequency range)

9. LSVT® Program-cont. 1 hour therapy sessions/4 times a week/1month
Receive hours of individual therapy

10. Essential Concepts of the LSVT® Program
Concept 1: Voice
Improving vocal fold adduction
Maximum impact on intelligibility
Immediate reinforcement
“THINK LOUD / THINK SHOUT”

11. Concepts-cont. Concept 2: High Effort Patient Rationale
Overrides rigidity and hypokinesia by pushing patients to new effort levels
Trains new target by putting the “load on the larynx”
Dealing with a progressive neurological disease
Clinician Rationale
Clinician effort equals patient effort
Lack of affect and physical condition of patient
Tendency to be reactive

12. Concepts-cont. Concept 3: Intensive Treatment
Daily opportunity to practice increases the chance of “building daily increments of vocal effort”
Maintain motivation and accountability
Maximize habituation and carry over
Provides an opportunity for clinician to see patient’s daily fluctuations

13. Concepts-cont. Concept 4: Calibration
The patient knows and accepts the amount of effort needed to consistently increase loudness that is within normal limits
Patient will use louder voice automatically
Problem scaling amplitude of motor output related to voice
Need to have “knowledge of results”
Convince patient that loud/strong voice is WNL
Habituation and carryover

14. Concepts-cont. Concept 5: Quantification
The key to motivate patient and provide feedback
Objective methods to document improvement
Precious speech treatment Ineffective/document efficacy
Reimbursement/referrals/ethics

15. Speech Production Tasks
Hierarchy activities:
Week 1: words
Week 2: Phrases
Week 3: Reading aloud
Week 4: Conversation

16. Overview of Program Incorporates: Daily variables
Hierarchical speech loudness drills
Integration of five essential concepts
The administration and integration of the techniques are designed specifically for voice/speech disorders associated with Parkinson disease

17. Necessary Data Measure vocal output (amplitude and pitch)
Necessary to provide feedback
Recognize spoken utterances at different stages of therapy
Current speech recognition systems are trained on “normal” speech
Speech data from those with Parkinson disease is needed

18. Limitations
Treatment dosage may not be possible for those with (1) physical limitations, (2) geographic barriers, (3) or financial reasons
Trained and certified clinicians are not available across the country
Lack of consistent insurance reimbursement may be an obstacle
Presently, only 3-4% of those with Parkinson disease receive speech treatment

19. Why is the LSVT® Program Successful?
“Loudness” functions as a single motor organizing theme which enhances overall speech
Intensive mode of administration is essential to maintain optimum treatment results
By incorporating sensory awareness training, the patient feels more comfortable using their new louder voice

20. Living Proof
Quote…
“I am 49, dx in August of this year. I just completed the Lee Silverman Voice Treatment on 12/6. I decided to do this program as a way to stall any possible decline in my voice quality not realizing that there had already been some decline. After the four weeks I got to see a video of myself done on the second day and a video made on the last day-the different was shocking and is great incentive for me to continue with the voice exercises twice a day. There will be re-evaluations done every six months and I’m determined to stay on top of this Improvement.
I am now more focused on what kind of day I am having and adjust my “effort” level accordingly. I just started Comtan yesterday to enhance a low dose of Sinemet and found this morning’s exercises to be much easier and of much longer duration in the high and low pitch sounds. Have also engaged the help of friends and co-workers to alert me to when my voice is too soft. I’m excited about the treatment and have hopes that if I remain dedicated to the exercising my voice quality will remain good. “
Department of Neurology at Massachusetts General Hospital-Webspinner WebForum
Retrieved March 26, 2003

21. Clinician Certification
Training and Certification workshop
1 ½ - 2 days
Provides:
A rationale for treating voice in motor speech disorders
Parkinson disease information
Treatment efficacy data
“Hands on” training with patients
Time for questions and discussion

22. Interested? Completing Training will result in:
Using the LSVT name as a Certified clinician
Use LSVT efficacy data to market and support reimbursement of LSVT programs
Receive an LSVT certificate suitable for display
Enroll in our database of LSVT Certified clinicians for patient and physician referrals
Receive updates of articles and any other relevant LSVT information
Receive The Phonator, a bi-annual newsletter
Subscribe to the LSVT listserv

23. Contact Information
Contact at:
LSVT® Foundation:

24. References
Boone, B.R. &McFarlane, S.C. (2000). The Voice and Voice Therapy (6th ed.). Needham Heights, MA: Ally & Bacon.
Cole, R., Ramig, L. (n.d.). Animated agent-enhanced voice treatment for individuals with Parkinson disease. Retrieved March 30, 2003 from University of Colorado, Boulder, The Center for Spoken Language Research Web site: /therapist_paper.pdf
Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor stability in IPD: effects of rate and loudness manipulations. Journal of Speech, Language, and Hearing Research, 44,
Lee Silverman Voice Treatment. (n.d.). LSVT® Certification. Retrieved March 30, 2003 from

25. References-cont.
Lee Silverman Voice Treatment. (n.d.). LSVT Training & Certification Workshop Bibliography.  Retrieved March 30, 2003 from
Lee Silverman Voice Treatment. (n.d.). What is the LSVT Foundation? Retrieved March 30, 2003 from
National Parkinson Foundation. (n.d.). Speech and voice problems in individuals with Parkinson disease. Retrieved March 30, 2003 from
No author. (1999, December 18). Completed treatment 12/6. Message posted to
The Lee Silverman Voice Treatment. (n.d.). Retrieved March 26, 2003, from Murray State University, Speech Science Web site: