The Lee Silverman Voice Treatment (LSVT) Approach

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The Lee Silverman Voice Treatment (LSVT) Approach

• Presented by
• Kim Miesen
• November 24, 2004

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What is the Lee Silverman Voice Treatment (LSVT)
Approach?

• Intensive voice treatment program
• Designed to teach an individual with Parkinsons
  disease to improve functional intelligible oral
  communication by increasing vocal loudness
• Treatment Duration
• 16 intensive individual sessions, 4x/week
• Maintenance 6 to 12 months (daily practice)

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History

• Originated at a clinic in Arizona
• Lee Silverman Center for Parkinsons Disease
• 15 years of experimental research funded by the
  National Institute of Health/National Institute
  on Deafness and other Communication Disorders
• 
  
  (LSVT What is it all
  about, 2004)
• Ramig and colleagues formalized their
  observations into the LSVT approach for treating
  individuals with Parkinsons disease in the last
  10 years. (Boone McFarlane, 2000)
• Hypothesis Based on the theory that reduced
  drive to respiratory and laryngeal musculature
  underlies reduced vocal loudness and monotonous
  speech observed in those with IPD.
  (Fox, Morrison, Ramig,
  Sapir, 2002, p. 112)
• 
  
  
• 
  
• 
  

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Research/Theory

• Model of Intention
• Researchers have based their intervention on the
  model of intention to help patients with PD
  improve their intelligibility.
• What does this mean?
• When subjects speak with intent, their speech was
  observed as slower and louder with better
  articulation and increased quality.
• Think Loud, Think Shout

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Efficacy Studies

• Outcome Data - Evidence of improvement in adults
  with Idiopathic Parkinsons disease
• Respiratory Level
• Increased subglottal air pressure
• Increased lung volume excursion
• Phonatory Level
• Increased sustained vowel phonation
• Increased maximum fundamental frequency range
  variability
• Improvements in vocal fold adduction
• Improvements in sound pressure level (SPL)

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Efficacy Studies (continued)

• Outcome Data Evidence of Improvement
• Articulation Level
• Motor Perspective
• Increased facial expression/affect
• Improvements in swallowingWhy?
• Researchers are unsure but believe swallowing may
  be brought under voluntary control based on the
  increased physiologic efforts associated with
  LSVT objectives (Yorkston, Miller, Strand,
  2004)

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Efficacy Studies (continued)

• Cognitive Perspective
• LSVT is not a cognitively demanding intervention
  approach (Sapir colleagues, 2003).
• Why is this important?
• Some individuals with PD present with symptoms of
  dementia (Sapir colleagues, 2003).
• Individuals with PD often have difficulty
  completing multi-step tasks (Yorkston, Miller,
  Strand, 2004).
• LSVT provides simple intervention tasks that are
  motivating to the individual (Yorkston, Miller,
  Strand, 2004).

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Research Who Benefits From LSVT?

• Parkinsons Disease
• Characteristics
• Rigidity, bradykinesia, hypokinesia, tremor
• Reduced loudness, hoarse voice quality
  (hypoadduction of the vocal folds), monotone
  pitch, imprecise articulation (Andrews, 1999)
• Why is this important?
• Patient presents with reduced speech
  intelligibility resulting in limitations for full
  participation in society. (Andrews, 1999)

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Research Who Benefits From LSVT (continued)?

• Other Neurological Disorders
• Ataxia - Stroke
• Multiple Sclerosis -Traumatic Brain Injury
• Limitations
• Positive outcomes in perceptual acoustic
  measures NOT in physiological changes
• Many research outcomes still based on
  single-subject designs

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Limitations

• 1. Current data is limited to ideal
  experimental conditions
• 2. Prognostic variables for success are not
  clearly defined
• 3. Best mode of administration for optimal
  results not established
• 4. Need for studies comparing those who
  participate in treatment focusing on phonation
  vs. articulation or rate
• 5. Positive long-term (2 year) outcome data based
  on group results NOT individual patient outcomes

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Specific Objectives of the LSVT Approach
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5 Essential Concepts/Rationale

• Focus on
• 1. VOICE
• 2. HIGH EFFORT
• 3. INTENSIVE TREATMENT
• 4. CALIBRATION
• 5. QUANTIFICATION

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Concept 1 Focus on Voice

• Goals
• Increase vocal fold adduction respiratory drive
• Provide maximal impact on intelligibility
• Provide immediate reinforcement
• THINK LOUD/THINK SHOUT

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Concept 2 Focus on High Effort

• Patient
• Overcome rigidity and hypokinesia
• Trains new target (rescale amplitude of motor
  output, i.e. larynx)
• Ability to manage a progressive neurological
  disease

• Clinician
• Clinician effort patient effort (scaling)
• Improves affect and physical condition of patient
• Therapy is reactive

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Concept 3 Focus on Intensive Treatment

• Goals
• 16 individual treatment sessions/month
• Daily practice opportunities increase probability
  of increasing vocal effort
• Maintain motivation accountability
• Maximize generalization (calibration)
• SLP is able to observe the patients daily
  fluctuations

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Concept 4 Focus on Calibration

• Definition The patient understands and accepts
  the amount of effort necessary to increase vocal
  loudness to a level that is within normal limits
• Goals
• Rescale perception of speech output
• Sensory feedback
• Convince patient that a loud/strong voice can be
  normal
• Carry over (21 days new habit)

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Concept 5 Quantification

• Motivate patient
• Provide feedback
• Objective method for documentation purposes
• Document efficacy (compare to previous speech
  intervention)
• Reimbursement/Referrals

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Summary LSVT the WHO Model

• Level of Impairment (Body)
• Decreases unintelligible, dysarthric speech
• LSVT increases functioning of all speech
  subsystems
• 
  (Fox, Morrison, Ramig, Sapir, 2002)
• Level of Whole Person (Activity)
• Immediate improvement of the whole person
• Increased ability to communicate in daily life
  situations based on increased intelligibility
  (Fox, Morrison, Ramig, Sapir, 2002)
• Level of Society (Participation)
• Improvements in relationships, community life
  etc.
• Individual will be motivated to continue their
  job, participate in family functions despite
  their neurological disorder (Andrews, 1999)

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LSVT Certification

• In order to use the name LSVT in a clinical
  setting (i.e. documentation), you must be
  certified by the LSVT Foundation
• Why?
• Evidence - based practice
• All published treatment outcomes are based on the
  results of patients who were treated by certified
  SLPs
• See the LSVT Foundation Website for workshop
  opportunities http//www.lsvt.org/

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Bibliography

• Andrews, M. L. (1999). Manual of voice treatment
  Pediatrics through geriatrics (2nd ed.). United
  States Singular.
• Boone, D. R., McFarlane, S. C. (2000). The
  voice and voice therapy (6th ed.). Boston Allyn
  and Bacon.
• Fox, C. M., Morrison, C. E., Ramig, L. O.,
  Sapir, S. (2002). Current perspectives on the Lee
  Silverman Voice Treatment (LSVT) for individuals
  with idiopathic Parkinson disease. American
  Journal of Speech-Language Pathology, 11(2),
  111-123.
• 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, 1041-1051.
• LSVT What is it all about? (2004). In LSVT
  Foundation Website. Retrieved on September 20,
  2004, from http//www.lsvt.org/faq.htm.
• Ramig, L., Pawlas, A., Countryman, S. (1995).
  The Lee Silverman Voice Treatment A practical
  guide for treating the voice and speech disorders
  in Parkinson disease. Iowa City, IA National
  Center for Voice and Speech.
• Sapir, S., Spielman, J., Ramig, L. O., Hinds, S.
  L., Countryman, S., Fox, C., Story, B. (2003).
  Effects of intensive voice treatment (the Lee
  Silverman Voice Treatment LSVT) on Ataxic
  Dysarthria A case study. American Journal of
  Speech-Language Pathology, 12(4), 387-399.
• Yorkston, K. M., Miller, R. M., Strand, E. A.
  (2004). Management of speech and swallowing in
  degenerative diseases (2nd ed.). Austin, TX
  PRO-ED, Inc.

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Questions?