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The Science and Practice of LSVT BIG Robert B. Leavitt PT, MPT, OCS, JSCC, LSVT cert. VP Operations OSPT Ph: 707-571-7615 Copyright LSVT.

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Presentation on theme: "The Science and Practice of LSVT BIG Robert B. Leavitt PT, MPT, OCS, JSCC, LSVT cert. VP Operations OSPT Ph: 707-571-7615 Copyright LSVT."— Presentation transcript:

1 The Science and Practice of LSVT BIG Robert B. Leavitt PT, MPT, OCS, JSCC, LSVT cert. VP Operations OSPT Ph: 707-571-7615 Copyright LSVT Global, Inc. 2011

2 Objectives Explain advances in neuroscience and impact on the field of rehabilitation Briefly discuss development and data on an efficacious speech treatment LSVT LOUD Describe development and key aspects of limb motor treatment LSVT BIG Introduce the LSVT HYBRID approach (simultaneous delivery of BIG and LOUD) Copyright LSVT Global, Inc. 2011

3 It is an exciting time to be in rehabilitation today!  Basic science evidence for the value of exercise in PD (classically drugs, surgery, today…)  Identified key principles of exercise that drive activity-dependent neural plasticity  Demonstrated that exercise can improve brain functioning (neural plasticity) and may slow disease progression  Exercise is Medicine! Kliem & Jones, 2008; Ludlow et al, 2008 Copyright LSVT Global, Inc. 2011

4 Legitimate Therapeutic Options To provide symptomatic relief; improve function Pharmacological (L-dopa) Voice and Body Exercise Neurosurgical (DBS-STN) Zigmond et al, 2009 Copyright LSVT Global, Inc. 2011

5 “If only we can hear and understand her” Family of Mrs. Lee Silverman 1987

6 5 Stages of Grief Denial - “There must be some mistake!” Anger – “I sure got shafted this time.” Bargaining – “There must be a cure.” Depression – “This is hopeless.” Acceptance – “ I can deal with this.” These stages must be worked through before any meaningful process can begin. Source: On Death and Dying. Elizabeth Kubler-Ross

7 20+ year journey from invention to intervention Over 8 million dollars in NIH funding 1987-89: Initial invention; Pilot data (Scottsdale) 1989-91: Office of Education OE-NIDRR 1991-94: OE-NIDRR 1990-95: NIH funded RCT Efficacy 1995-00: NIH funded EMG, Kinematics 2002-07: NIH funded RCT Spread of effects 2007-12: NIH funded RCT, imaging 2001-02: Coleman Institute (PDA; LSVTC) 2002-04: NIH and M J FOX Foundation PDA (R21) 2002-04: Coleman Institute (VT; LSVTVT) 2004-06: NIH LSVTVT (R21) 2004 : Coleman Institute (LSVT Down Syndrome) 2004-07: LSVT –Dissemination 2006: Technology-enhanced Clinician Training (SBIR) 2010: Technology-enhanced LSVT LOUD delivery (SBIR) Phase I, II Phase III Phase IV, V Copyright LSVT Global, Inc. 2011

8 Administered in an intensive manner to to challenge the impaired system. Techniques specific to PD-specific deficits! bradykinesia/hypokinesia and kinesthetic awareness (sensory deficit) LSVT Programs Copyright LSVT Global, Inc. 2011

9 SOFT LOUD HEALTHY LOUDNESS Neural coupling (McClean and Tasko) Loud is more than a laryngeal event – spread of effects TARGET of LSVT LOUD

10 sensory problem, internal cueing Learning CALIBRATION

11 Imaging Studies with LSVT LOUD Liotti, Ramig, et al, 2003 Copyright LSVT Global, Inc. 2011

12 LSVT LOUDLSVT BIG (Farley & Koshland, 2005; Farley, Fox, et al., 2008; Farley & Koshland, in revision)

13 What are the fundamentals of LSVT BIG? TARGET: Bigness (amplitude) MODE: Intensive and High Effort CALIBRATION: Generalization Sensory Internal cueing Neuropsychological changes Standardized, research-based, specific protocol Copyright LSVT Global, Inc. 2011

14 BIG (Large amplitude whole body movement) Single Target - Triggers Activation across motor systems SMALL BIG NORMAL “BIGNESS“ TARGET

15 Delivery –Certified LSVT BIG Physical/Occupational Therapist 1:1 intervention Time of Practice –4 consecutive days per week for 4 weeks –16 sessions in one month –60 minute sessions –Daily carryover assignments (30 days/entire month) –Daily homework (30 days/entire month) MODE Copyright LSVT Global, Inc. 2011

16 MISMATCH between self-perception of output and how others perceive it “ I had no idea how small my world had become” “I can’t move like this, people will think I am crazy!!” CALIBRATION

17 Retrain sensory calibration and learn new internal cues for normal movement effort and bigness CALIBRATION Learning Copyright LSVT Global, Inc. 2011

18 Impaired self-perception Small movements reduced amplitude of output Deficits in internal cues

19 Increase Bigness increase amplitude of output Self-perception, Internal cues, Simple, Redundant Mode Intensive, High effort (consistent with principles of neural plasticity) Target Calibration Goal of LSVT BIG

20 Treatment Session Daily Exercises 1.Floor to Ceiling 2.Side to Side 3.Forward step 4.Sideways step 5.Backward step 6.Forward Rock and Reach 7.Sideways Rock and Reach Functional Component Tasks 5 EVERYDAY TASKS– 5 reps each For Example: - Sit-to-Stand -Pulling keys out of pocket -Opening refrigerator door Walking BIG distance/time may vary Hierarchy Tasks Patient identified tasks: Getting out of bed Playing golf In and out of a car Build complexity across 4 weeks of treatment towards long term goals Copyright LSVT Global, Inc. 2011

21 Daily Whole-body Maximal Amplitude Exercises Multidirectional Sustained Movements Floor to Ceiling Side to Side Copyright LSVT Global, Inc. 2011

22 Daily Whole-body Maximal Amplitude Exercises Multidirectional Repetitive Movements Forwards Sideways Backwards Copyright LSVT Global, Inc. 2011

23 Rolling Floor to Stand Getting in or out of bed Sit to stand Sit & reach Stand & reach Walk & reach Walk & turn Stand & turn Functional Component TASKS Functional Components – Patient DRIVEN! Sit to stand BIG Copyright LSVT Global, Inc. 2011

24 Daily Hierarchical Tasks “Real-World” BIG Tasks – Patient DRIVEN! Examples: Bed to Bathroom In/Out of Car Walk and Talk Tennis Chores Golf Hiking Gardening Copyright LSVT Global, Inc. 2011

25 Patient case: Bernie 71 year-old, diagnosed with Parkinson’s disease in 1994 Reason for referral: slowness and difficulty walking, history of falls, freezing Optimized on PD medications Copyright LSVT Global, Inc. 2011

26 Objective Outcomes: Falls1-2/month0/month Assistive deviceCaneNone Confidence37.5%56.8% Gait Velocity0.35 m/s1.17 m/s % of age matched norm 29.6 %100% Endurance730 ft1200 ft PREPOST Copyright LSVT Global, Inc. 2011

27 Bernie’s Goals To improve his walking To go to the movies To play with his grandchildren To go out to dinner with friends and family All accomplished to his satisfaction! Copyright LSVT Global, Inc. 2011

28 Randomized Comparative Pilot Study Matched Frequency/Duration 4X/week for 4 weeks; 1-hour individual sessions N=42 Hoehn & Yahr 1-3 Intention to treat analysis Farley & Koshland, in preparation (Unpublished data) LSVT BIG vs. Traditional Outpatient Physical Therapy

29 Walking Improvements Farley & Koshland, in preparation (Unpublished data) Improvements occurred in both groups and lasted 3 months. TRAD BIG FasterBigger 3-months 1-month Better Copyright LSVT Global, Inc. 2011

30 Trunk Rotation Farley & Koshland, in preparation (Unpublished data) Only improved for LSVT BIG TRAD BIG 3-months1-month Better Copyright LSVT Global, Inc. 2011

31 Activity Matters LSVT BIG may be especially important for trunk rotation and balance - everyday movements Conclusions:

32 Principles of LSVT applied simultaneously to the speech and limb motor systems.  Combined or “Hybrid” approach for PD  May promote greater plasticity through greater intensity, complexity, saliency  Enhance practical, logistical, financial costs of PD rehabilitation LSVT HYBRID = LOUD + BIG Copyright LSVT Global, Inc. 2011

33 LSVT HYBRID retrains “normal use” “In my normal everyday life, I just exaggerate my movements. I keep things Big when I reach for things, or when I bend or when I walk; and when I talk – I keep my voice strong.” Copyright LSVT Global, Inc. 2011

34 Summary Advances in neuroscience have provided neurobiological and behavioral evidence supporting the positive impact of exercise-based protocols in people with PD There is a rapidly growing literature in physical therapy/exercise protocols in humans with PD LSVT Programs have been developed and studied over the past 20 years LSVT BIG is one type of physical therapy program that has potential to offer improvements in movement and quality of life for people with PD Copyright LSVT Global, Inc. 2011

35 “It is possible to take charge of your life, even with Parkinson’s. It is possible for your will to override your brain. It is possible to have Power Over Parkinson’s” Sharon Kha, LSVT BIG and LSVT LOUD Graduate

36 “Fear is an emotional “germ” that will destroy the spirit. Filling your brain with “I can thoughts” will turn fear away” “No matter what the reason for it, inactivity is unhealthy. The less active we are the weaker we become and the more likely we are to develop obesity, osteoporosis, diabetes, and heart disease.” Source: Take Charge of Your Chronic Pain. Peter Abaci, MD. Globe Pequot Press.

37 Thank you for your attention! Presented by Robert B. Leavitt PT, MPT, OCS, JSCC VP Operations OSPT 795 Farmers Lane Santa Rosa, CA 95405 Ph: 707-571-7615 More info available at

38 Lee Silverman Voice Therapy: Rehabilitative Therapy for People with Parkinson’s Parkinson’s Support Group January 19th, 2013 Oakmont Santa Rosa, CA Presented by: Dr. Deborah Swain, Ed. D, CCC-SLP The Swain Center 795 Farmers Lane, Suite 23 Santa Rosa, CA 95405 (707) 575-1468

39 Lee Silverman Voice Therapy (LSVT®) Introduction The LSVT® LOUD improves both the voice and speech of individuals with Parkinson’s Disease by treating the underlying physical pathology associated with the disordered voice Treatment focuses on improving vocal loudness and immediate carryover into daily communication enabling patients to maintain and/or improve their oral communication The LSVT® LOUD is administered on an intensive schedule of 16 individual, 60-minute sessions in one month’s time

40 LSVT® Introduction 90% of patients improve vocal loudness from pre to post-treatment Approximately 80% of patients maintain treatment improvements in their voice for 12-24 months post-treatment ALL patients report improvement in their ability to communicate ®LSVT® LOUD is being successfully delivered by over 4,000 certified LSVT® clinicians in 41 countries

41 Goal of LSVT® Patient uses his or her voice “automatically” in daily communication There is a carryover of this information for the long term

42 Need for LSVT® LOUD Few patients with motor speech disorders receive treatment with well- documented efficacy –89% of patients with Parkinson’s Disease have disordered speech (Logemann et al, 1978) –But only 4% of those individuals receive treatment (Mutch et al, 1986; Hartelius & Sveenson, 1994)

43 Why Treat Phonation in Neurological Disorders? Motor speech disorders accompanying neurological disorders limit functional oral communication Oral communication is a vital element in: –Education –Employment –Social functioning –Self expression Treatment of one area of speech enhances many levels of speech production –Improves capability of treatment –Simplifies treatment

44 LSVT® LOUD as a Trigger Improves articulation Enhances “source” of speech –Turns up the volume –Improves vocal fold movements Acts as a trigger –Vocal tract effects Reduces spread of effects

45 Speech Behaviors in Parkinson’s Disease Reduced volume of speech is a key factor in Parkinson’s Disease –Patients can sometimes feel like they are shouting to be heard Voice must be stimulated in order to successfully increase loudness and enable speech to be heard

46 Soft Voice Loop

47 Origins of Speech Disorders in Parkinson’s Disease Motor challenges Sensory challenges Neuropsychological (cueing) challenges

48 Neuropsychological Challenges Internally vs. Externally Cued Movements –Parkinson’s Disease results in patients being unable to self-initiate speech –Deficits in self-initiated movements are due to an under-activation of Sensory Motor Areas

49 Perceptual Characteristics Reduced loudness Hoarse voice quality Monotone Imprecise articulation Vocal tremors –Some patients report reduced volume, a hoarse voice or being monotone as the first symptom on Parkinson’s Disease Lowering of functional oral communication –Less likely to participate in conversations or have confidence in their voice (Fox and Ramig, 1997)

50 LSVT® LOUD Impact LSVT® LOUD participants:Some responses from LSVT® LOUD participants: –“My voice is alive again” –“I can talk to my grandchildren!” –“I feel like my old self” –“I am confident I can communicate!”

51 LSVT® LOUD Methods Assessment LSVT® LOUD –Separate from 16 sessions of LSVT® LOUD OverviewOverview –4 days a week for 4 weeks (16 sessions in 1 month) –50-60 minute sessions Integration of five essential conceptsIntegration of five essential concepts –All focus on voice –All are high effort –All are completed daily –All are tools for calibration –All are quantified

52 LSVT® LOUD Design Designed to allow a patient to consistently progress to desired functional speech level Designed to help a patient build their ability and reduce frustration Designed to bring voice rescaling back into speech Both vocal loudness level and calibration are addressed in this hierarchy

53 Voice Training with LSVT® LOUD Maximize phonatory efficiency by increasing loudness – KEY Rescale phonatory loudness and effort Voice is #1 priority Keep it simple

54 LSVT® LOUD Work at Home Designed to: –Provide additional practice –Enable patient to become comfortable with the use of a high vocal effort –Establish a routine schedule of practice at home “Brush your teeth – do your ‘Ah’s” Methods: –5 – 10 minutes one other time on treatment days –10-15 minutes twice daily on non-treatment days

55 LSVT® LOUD Post-Treatment Model Practice at home Complete treatment tasks LSVT® LOUD Homework Helper can be used at homeLSVT® LOUD Homework Helper can be used at home Six months post-treatment:Six months post-treatment: –Check-in with clinician –More severe patients may check in earlier (around two months) Patients may end up needing:Patients may end up needing: –One or two “tune-up sessions” –Enhanced motivation –Calibration rescaling

56 LOUD Crowd Following completion of the 4-week program each patient enters the maintenance phase of the Northern California Voice Project’s program and becomes a member of the “LOUD Crowd.” Meets the challenge of maintaining the speech and swallowing gains attained from the intensive Lee Silverman Voice Therapy program. Loud Crowd provides support, encouragement, and continued care from a certified speech-language pathologist. Patients who participate in continued voice maintenance have been shown to maintain their improved voices for more than five years.

57 LSVT® LOUD Model for Treatment of Individuals with Parkinson’s Disease


59 Changes in Vocal Loudness in Individuals with Parkinson's Disease Following LSVT® Ramig, Sapir, et al. (2001) –This study assessed the impact of the Lee Silverman Voice Treatment (LSVT®) on vocal loudness (Sound Pressure Level – SPL) in a group of individuals with Parkinson's disease –The individuals treated with LSVT® increased voice vocal loudness (SPL) from by an average of 8 decibels (dB) and from baseline to 6 months follow-up by an average of 6 dB These changes were statistically significant and perceptibly audible –Treated patients showed a significant increase in vocal loudness (SPL); this was statistically significant for all voice and speech tasks These findings, along with others, provide additional support for the efficacy of the LSVT®

60 Questions & Comments

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