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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) History 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) Research/Theory n Model of Intention: n Researchers have based their intervention on the “model of intention” to help patients with PD improve their intelligibility. 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 & variability § 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 LSVT? 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 (continued)? 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) 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 (Fox, Morrison, Ramig, & Sapir, 2002) Specific Objectives of the LSVT Approach 5 Essential Concepts/Rationale n Focus on… 1. VOICE 2. HIGH EFFORT 3. INTENSIVE TREATMENT 4. CALIBRATION 5. QUANTIFICATION (Ramig, Pawlas, & Countryman, 1995) Concept 1: Focus on Voice n Goals: – Increase vocal fold adduction & respiratory drive – Provide maximal impact on intelligibility – Provide immediate reinforcement – “THINK LOUD/THINK SHOUT” (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 progressive neurological disease (Ramig, Pawlas, & Countryman, 1995) Concept 3: Focus on Intensive Treatment 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 fluctuations (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 normal – Carry over (21 days = new habit) (Ramig, Pawlas, & Countryman, 1995) Concept 5: Quantification n Motivate patient n Provide feedback n Objective method for documentation purposes 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, 1999) (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) Bibliography 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 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. Questions?
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