Presented by:Presented by:Andrea BossuytAndrea Bossuyt

4/1/20034/1/2003

Lee Silverman Voice Lee Silverman Voice Treatment (LSVTTreatment (LSVT®®))

LSVTLSVT®® Foundation Foundation

LSVTLSVT®® founder: founder: Lorraine Olson Ramig, Ph.D., CCC-SLPLorraine Olson Ramig, Ph.D., CCC-SLP Professor, University of Colorado-BoulderProfessor, University of Colorado-Boulder

Research Associate, Wilbur James GouldResearch Associate, Wilbur James Gould Voice Research Center, Denver, ColoradoVoice Research Center, Denver, Colorado

What is the LSVTWhat is the LSVT®® Foundation?Foundation?

A Colorado non-profit organization A Colorado non-profit organization dedicated to improving dedicated to improving communication for those with a communication for those with a neurological disorderneurological disorder

With a specialty is in Parkinson diseaseWith a specialty is in Parkinson disease

Holds a certification mark /Holds a certification mark /®/®/ to insure to insure the quality and standard of the the quality and standard of the foundationfoundation

LSVTLSVT®® Foundation Goals Foundation Goals Training and updating Training and updating

clinicians in the LSVTclinicians in the LSVT®®

Educating other health Educating other health care professionals about care professionals about the importance of LSVTthe importance of LSVT®® and the positive and the positive outcomes outcomes

Providing information Providing information services, such the LSVTservices, such the LSVT clinician referral clinician referral database, patient and database, patient and clinician newsletter, clinician newsletter, listserves, and web pageslistserves, and web pages

Parkinson DiseaseParkinson Disease Affects approximately 10% of Americans over the age of 60.Affects approximately 10% of Americans over the age of 60.

75-100% also develop speech and voice problems (Kleinow et 75-100% also develop speech and voice problems (Kleinow et al, 2001)al, 2001)

“…“…is a generative, progressive disease of the basal ganglia, is a generative, progressive disease of the basal ganglia, manifesting itself in a hypokinetic dysarthria, nonintention tremor manifesting itself in a hypokinetic dysarthria, nonintention tremor (at-rest tremor), with sluggish intonation of motor movements (at-rest tremor), with sluggish intonation of motor movements (such as gait). (such as gait).

Hypokinetic DysarthriaHypokinetic Dysarthria Reduced loudnessReduced loudness Breathy voiceBreathy voice Monotony of pitchMonotony of pitch Intermittent rapid rushes of speechIntermittent rapid rushes of speech Soft production of consonantsSoft production of consonants

(Boone & (Boone & MacFarlane, 2000) MacFarlane, 2000)

Voice Therapy for Parkinson Voice Therapy for Parkinson Disease?Disease?

Significant respiratory difficulties and bowed Significant respiratory difficulties and bowed vocal folds have been reported as causes of voice vocal folds have been reported as causes of voice symptoms in those with Parkinson diseasesymptoms in those with Parkinson disease

The most effective approach has been to The most effective approach has been to exaggerate one component of speech to improve exaggerate one component of speech to improve all other components (e.g. loudness, voice, all other components (e.g. loudness, voice, quality, pitch, rate)quality, pitch, rate) These observations has been formalized into the LSVTThese observations has been formalized into the LSVT®®

Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor stability in IPD: Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor stability in IPD: effects of rate and loudness manipulations. effects of rate and loudness manipulations. Journal of Speech, Journal of Speech, Language, and Hearing Research, 44Language, and Hearing Research, 44, 1041-51. , 1041-51.

LSVTLSVT®® Program Program

11stst speech treatment with short and speech treatment with short and long-term efficacy data documenting long-term efficacy data documenting increased functional communicationincreased functional communication

Research has been supported by the Research has been supported by the National Institutes of Health (NIH) National Institutes of Health (NIH) and the National Institute for and the National Institute for Deafness and other Communication Deafness and other Communication Disorders (NIDCD) Disorders (NIDCD)

LSVTLSVT®® Program Program The program incorporatesThe program incorporates::

Enhancing the vocal source (adduction)Enhancing the vocal source (adduction)

Using phonation as a trigger to increase effort Using phonation as a trigger to increase effort and coordination through stimulating the and coordination through stimulating the “loud” global variable (respiratory support)“loud” global variable (respiratory support)

Retraining sensory processing during the Retraining sensory processing during the speech production (increasing fundamental speech production (increasing fundamental frequency range)frequency range)

LSVTLSVT®® Program-cont. Program-cont.

1 hour therapy sessions/4 times a 1 hour therapy sessions/4 times a week/1monthweek/1month

Receive 13-16 hours of individual therapyReceive 13-16 hours of individual therapy

Essential Concepts of the Essential Concepts of the LSVTLSVT®® Program Program

Concept 1: VoiceConcept 1: Voice

Improving vocal fold adductionImproving vocal fold adduction

Maximum impact on intelligibilityMaximum impact on intelligibility

Immediate reinforcementImmediate reinforcement

““THINK LOUD / THINK SHOUT”THINK LOUD / THINK SHOUT”

Concepts-cont.Concepts-cont. Concept 2: High EffortConcept 2: High Effort

Patient RationalePatient Rationale Overrides rigidity and hypokinesia by pushing Overrides rigidity and hypokinesia by pushing

patients to new effort levelspatients to new effort levels Trains new target by putting the “load on the larynx”Trains new target by putting the “load on the larynx” Dealing with a progressive neurological diseaseDealing with a progressive neurological disease

Clinician RationaleClinician Rationale Clinician effort equals patient effortClinician effort equals patient effort Lack of affect and physical condition of patientLack of affect and physical condition of patient Tendency to be reactiveTendency to be reactive

Concepts-cont.Concepts-cont.

Concept 3: Intensive TreatmentConcept 3: Intensive Treatment

Daily opportunity to practice increases the chance of Daily opportunity to practice increases the chance of “building daily increments of vocal effort”“building daily increments of vocal effort”

Maintain motivation and accountabilityMaintain motivation and accountability

Maximize habituation and carry overMaximize habituation and carry over

Provides an opportunity for clinician to see patient’s Provides an opportunity for clinician to see patient’s daily fluctuationsdaily fluctuations

Concepts-cont.Concepts-cont. Concept 4: CalibrationConcept 4: Calibration

The patient knows and accepts the amount of effort The patient knows and accepts the amount of effort needed to consistently increase loudness that is within needed to consistently increase loudness that is within normal limitsnormal limits Patient will use louder voice automatically Patient will use louder voice automatically

Problem scaling amplitude of motor output related to Problem scaling amplitude of motor output related to voicevoice

Need to have “knowledge of results”Need to have “knowledge of results”

Convince patient that loud/strong voice is WNLConvince patient that loud/strong voice is WNL

Habituation and carryoverHabituation and carryover

Concepts-cont.Concepts-cont. Concept 5: QuantificationConcept 5: Quantification

The key to motivate patient and provide The key to motivate patient and provide feedbackfeedback

Objective methods to document Objective methods to document improvementimprovement

Precious speech treatment Precious speech treatment Ineffective/document efficacyIneffective/document efficacy

Reimbursement/referrals/ethicsReimbursement/referrals/ethics

Speech Production TasksSpeech Production Tasks

Hierarchy activities:Hierarchy activities:

Week 1: wordsWeek 1: words

Week 2: PhrasesWeek 2: Phrases

Week 3: Reading aloudWeek 3: Reading aloud

Week 4: ConversationWeek 4: Conversation

Overview of ProgramOverview of Program Incorporates:Incorporates:

Daily variablesDaily variables

Hierarchical speech loudness drillsHierarchical speech loudness drills

Integration of five essential conceptsIntegration of five essential concepts

The administration and integration of the The administration and integration of the techniques are designed specifically for techniques are designed specifically for voice/speech disorders associated with voice/speech disorders associated with Parkinson diseaseParkinson disease

Necessary DataNecessary Data Measure vocal output Measure vocal output

(amplitude and pitch)(amplitude and pitch) Necessary to provide Necessary to provide

feedbackfeedback

Recognize spoken Recognize spoken utterances at different utterances at different stages of therapystages of therapy

Current speech recognition Current speech recognition systems are trained on systems are trained on “normal” speech“normal” speech Speech data from those Speech data from those

with Parkinson disease is with Parkinson disease is neededneeded

LimitationsLimitations Treatment dosage may not be possible for those Treatment dosage may not be possible for those

with (1) physical limitations, (2) geographic with (1) physical limitations, (2) geographic barriers, (3) or financial reasonsbarriers, (3) or financial reasons

Trained and certified clinicians are not available Trained and certified clinicians are not available across the countryacross the country

Lack of consistent insurance reimbursement may Lack of consistent insurance reimbursement may be an obstaclebe an obstacle

Presently, only 3-4% of those with Parkinson Presently, only 3-4% of those with Parkinson disease receive speech treatmentdisease receive speech treatment

Why is the LSVTWhy is the LSVT®® Program Program Successful?Successful?

““Loudness” functions as a single motor Loudness” functions as a single motor organizing theme which enhances overall organizing theme which enhances overall speechspeech

Intensive mode of administration is Intensive mode of administration is essential to maintain optimum treatment essential to maintain optimum treatment resultsresults

By incorporating sensory awareness By incorporating sensory awareness training, the patient feels more training, the patient feels more comfortable using their new louder voicecomfortable using their new louder voice

Living ProofLiving Proof Quote…Quote…

““I am 49, dx in August of this year. I just completed the Lee Silverman 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 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 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 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 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 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 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.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 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 “effort” level accordingly. I just started Comtan yesterday to enhance a low dose of Sinemet and found this morning’s exercises to be much 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. 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 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 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 hopes that if I remain dedicated to the exercising my voice quality will remain good. “ remain good. “

Department of Neurology at Department of Neurology at Massachusetts Massachusetts General Hospital-General Hospital-Webspinner WebForumWebspinner WebForum

Retrieved March 26, 2003Retrieved March 26, 2003

Clinician CertificationClinician Certification

Training and Certification Training and Certification workshopworkshop 1 ½ - 2 days 1 ½ - 2 days Provides:Provides:

A rationale for treating voice in motor A rationale for treating voice in motor speech disorders speech disorders

Parkinson disease informationParkinson disease information Treatment efficacy dataTreatment efficacy data ““Hands on” training with patientsHands on” training with patients Time for questions and discussionTime for questions and discussion

Interested?Interested? Completing Training will result inCompleting Training will result in::

Using the LSVTUsing the LSVT name as a Certified clinician name as a Certified clinician

Use LSVTUse LSVT efficacy data to market and support reimbursement of LSVT efficacy data to market and support reimbursement of LSVT programs programs

Receive an LSVTReceive an LSVT certificate suitable for display certificate suitable for display

Enroll in our database of LSVTEnroll in our database of LSVT Certified clinicians for patient and physician Certified clinicians for patient and physician referrals referrals

Receive updates of articles and any other relevant LSVTReceive updates of articles and any other relevant LSVT information information

Receive The Phonator, a bi-annual newsletterReceive The Phonator, a bi-annual newsletter

Subscribe to the LSVTSubscribe to the LSVT listserv listserv

Contact InformationContact Information

Contact at:Contact at:

http://http://www.lsvt.orgwww.lsvt.org

LSVTLSVT®® Foundation: 1-888-606-5788 Foundation: 1-888-606-5788

lsvtvp@aol.comlsvtvp@aol.com

ReferencesReferences Boone, B.R. &McFarlane, S.C. (2000). The Voice and Voice Boone, B.R. &McFarlane, S.C. (2000). The Voice and Voice

Therapy Therapy (6(6thth ed.). Needham Heights, MA: Ally & Bacon. ed.). Needham Heights, MA: Ally & Bacon. Cole, R., Ramig, L. (n.d.). Cole, R., Ramig, L. (n.d.). Animated agent-enhanced voice Animated agent-enhanced voice

treatment for individuals with Parkinson disease. treatment for individuals with Parkinson disease. Retrieved Retrieved March 30, 2003 from University of Colorado, March 30, 2003 from University of Colorado, Boulder, The Boulder, The Center for Spoken Language Research Web site: Center for Spoken Language Research Web site: http://http://cslr.colorado.edu/beginweb/animated_speech_therapistcslr.colorado.edu/beginweb/animated_speech_therapist//therapist_paper.pdftherapist_paper.pdf

Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor Kleinow, J., Smith, A., Ramig, L.O. (2001). Speech motor stability in IPD: effects of rate and loudness stability in IPD: effects of rate and loudness manipulations. manipulations. Journal of Speech, Language, and Journal of Speech, Language, and Hearing Research, 44Hearing Research, 44, , 1041-51. 1041-51.

Lee Silverman Voice Treatment. (n.d.). LSVTLee Silverman Voice Treatment. (n.d.). LSVT®® Certification. Certification. Retrieved March 30, 2003 from Retrieved March 30, 2003 from http://www.lsvt.org/main_site.htm http://www.lsvt.org/main_site.htm

References-cont.References-cont.

Lee Silverman Voice Treatment. (n.d.). LSVTLee Silverman Voice Treatment. (n.d.). LSVT Training & Training & Certification Workshop Bibliography.  Retrieved Certification Workshop Bibliography.  Retrieved

March 30, 2003 from March 30, 2003 from http://www.lsvt.org/main_site.htmhttp://www.lsvt.org/main_site.htm Lee Silverman Voice Treatment. (n.d.). What is the LSVTLee Silverman Voice Treatment. (n.d.). What is the LSVT

Foundation? Retrieved March 30, 2003 from Foundation? Retrieved March 30, 2003 from http://www.lsvt.org/main_site.htm http://www.lsvt.org/main_site.htm

National Parkinson Foundation. (n.d.). Speech and voice National Parkinson Foundation. (n.d.). Speech and voice problems in individuals with Parkinson disease. problems in individuals with Parkinson disease. Retrieved Retrieved March 30, 2003 from March 30, 2003 from http://www.parkinson.org/voice.htmhttp://www.parkinson.org/voice.htm

No author. (1999, December 18). Completed treatment No author. (1999, December 18). Completed treatment 12/6. Message posted to 12/6. Message posted to http://neuro-http://neuro-www.mgh.harvard.edu/forum_2/ParkinsonsDiseaseFwww.mgh.harvard.edu/forum_2/ParkinsonsDiseaseF

The Lee Silverman Voice Treatment. (n.d.). Retrieved The Lee Silverman Voice Treatment. (n.d.). Retrieved March March 26, 2003, from Murray State University, Speech 26, 2003, from Murray State University, Speech Science Science Web site: Web site: http://mick.murraystate.edu/cdi624/fall97/slvrman.htmhttp://mick.murraystate.edu/cdi624/fall97/slvrman.htm