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

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

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

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

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)

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, 1041-51.

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)

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)

LSVT® Program-cont. 1 hour therapy sessions/4 times a week/1month Receive 13-16 hours of individual therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

Contact Information Contact at: http://www.lsvt.org LSVT® Foundation: 1-888-606-5788 lsvtvp@aol.com

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: http://cslr.colorado.edu/beginweb/animated_speech_therapist /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, 1041-51. Lee Silverman Voice Treatment. (n.d.). LSVT® Certification. Retrieved March 30, 2003 from http://www.lsvt.org/main_site.htm

References-cont. Lee Silverman Voice Treatment. (n.d.). LSVT Training & Certification Workshop Bibliography.  Retrieved March 30, 2003 from http://www.lsvt.org/main_site.htm Lee Silverman Voice Treatment. (n.d.). What is the LSVT Foundation? Retrieved March 30, 2003 from http://www.lsvt.org/main_site.htm National Parkinson Foundation. (n.d.). Speech and voice problems in individuals with Parkinson disease. Retrieved March 30, 2003 from http://www.parkinson.org/voice.htm No author. (1999, December 18). Completed treatment 12/6. Message posted to http://neuro- www.mgh.harvard.edu/forum_2/ParkinsonsDiseaseF The Lee Silverman Voice Treatment. (n.d.). Retrieved March 26, 2003, from Murray State University, Speech Science Web site: http://mick.murraystate.edu/cdi624/fall97/slvrman.htm