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									  The Lee Silverman Voice
Treatment (LSVT) Approach

        Presented by:
         Kim Miesen
      November 24, 2004
  What is the Lee Silverman Voice
   Treatment (LSVT) Approach?
n Intensive   voice treatment program:
  – Designed to teach an individual with
    Parkinson’s disease to improve functional
    intelligible oral communication by increasing
    vocal loudness
n Treatment    Duration:
  – 16 intensive individual sessions, 4x/week
  – Maintenance: 6 to 12 months (daily practice)

                     (Andrews, 1999)
n   Originated at a clinic in Arizona
    – “Lee Silverman Center for Parkinson’s 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)

n   Ramig and colleagues formalized their observations
    into the LSVT approach for treating individuals with
    Parkinson’s 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)
n Model   of Intention:
n Researchers have based their intervention
  on the “model of intention” to help
  patients with PD improve their
n 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”

                  (Boone & McFarlane, 2000)
                Efficacy Studies
n Outcome  Data - Evidence of improvement in
 adults with Idiopathic Parkinson’s disease
  – Respiratory Level:
    § Increased subglottal air pressure
    § Increased lung volume excursion
  – Phonatory Level:
    § Increased sustained vowel phonation
    § Increased maximum fundamental frequency range &
    § Improvements in vocal fold adduction
    § Improvements in sound pressure level (SPL)
                      (Kleinow, Smith, & Ramig, 2001)
  Efficacy Studies (continued)
n Outcome    Data – Evidence of Improvement
  – Articulation Level
  – Motor Perspective
     § Increased facial expression/affect
     § Improvements in swallowing—Why?
       – 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)

                   (Fox, Morrison, Ramig, & Sapir, 2002)
   Efficacy Studies (continued)
n 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).
    Research: Who Benefits From
n Parkinson’s    Disease
  – Characteristics:
     § Rigidity, bradykinesia, hypokinesia, tremor
     § Reduced loudness, hoarse voice quality
       (hypoadduction of the vocal folds), monotone
       pitch, imprecise articulation (Andrews, 1999)
n Why   is this important?
  – Patient presents with reduced speech
    intelligibility resulting in limitations for full
    participation in society. (Andrews, 1999)
Research: Who Benefits From LSVT
n Other   Neurological Disorders:
  – Ataxia                                 - Stroke
  – Multiple Sclerosis                     -Traumatic Brain Injury
n Limitations:
  – Positive outcomes in perceptual & acoustic
    measures NOT in physiological changes
  – Many research outcomes still based on single-
    subject designs

                 (Fox, Morrison, Ramig, & Sapir, 2002)
1. Current data is limited to “ideal experimental
2. Prognostic variables for success are not clearly
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
                 (Fox, Morrison, Ramig, & Sapir, 2002)
Specific Objectives of
 the LSVT Approach
 5 Essential Concepts/Rationale
n Focus   on…

    1. VOICE

                (Ramig, Pawlas, & Countryman, 1995)
    Concept 1: Focus on Voice
n Goals:
  – Increase vocal fold adduction & respiratory

  – Provide maximal impact on intelligibility

  – Provide immediate reinforcement


                 (Ramig, Pawlas, & Countryman, 1995)
Concept 2: Focus on High Effort
n   Patient:                           n    Clinician:
    – Overcome rigidity and                  – Clinician effort =
      hypokinesia                              patient effort (scaling)
    – Trains new target                      – Improves affect and
      (rescale amplitude of                    physical condition of
      motor output, i.e.                       patient
      larynx)                                – Therapy is reactive
    – Ability to manage a
      neurological disease

                    (Ramig, Pawlas, & Countryman, 1995)
   Concept 3: Focus on Intensive
n Goals:
n 16  individual treatment sessions/month
n Daily practice opportunities increase
  probability of increasing vocal effort
n Maintain motivation & accountability
n Maximize generalization (calibration)
n SLP is able to observe the patient’s daily
               (Ramig, Pawlas, & Countryman, 1995)
Concept 4: Focus on Calibration
n   Definition: The patient understands and accepts
    the amount of effort necessary to increase vocal
    loudness to a level that is within normal limits…

n   Goals:
    – Rescale perception of speech output
    – Sensory feedback
    – Convince patient that a loud/strong voice can be
    – Carry over (21 days = new habit)

                    (Ramig, Pawlas, & Countryman, 1995)
    Concept 5: Quantification
n Motivate patient
n Provide feedback
n Objective method for documentation
n Document efficacy (compare to previous
  speech intervention)
n Reimbursement/Referrals

              (Ramig, Pawlas, & Countryman, 1995)
             Summary: LSVT & the
                “WHO Model”
n   Level of Impairment (Body):
    – Decreases unintelligible, dysarthric speech
    – LSVT increases functioning of all speech subsystems
                                                  (Fox, Morrison, Ramig, & Sapir, 2002)

n   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)
n   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,

                           (Class handout, King, 2004)
          LSVT Certification
n In  order to use the name “LSVT” in a
  clinical setting (i.e. documentation), you
  must be certified by the LSVT Foundation
n 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/
                ("LSVT: What Is It All About," 2004)
Andrews, M. L. (1999). Manual of voice treatment: Pediatrics through geriatrics (2 nd ed.). United
    States: Singular.

Boone, D. R., & McFarlane, S. C. (2000). The voice and voice therapy (6th ed.). Boston: Allyn and

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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