The LSVT® Story…How did we get to where we are today?
By Lorraine Olson Ramig, Ph.D., CCC-SLP
In 1983, Dr. Wilbur Gould walked into the acoustics lab at the Recording and Research Center of the Denver Center for the Performing Arts and said to me, “Lori, I have a friend who has a Parkinson disease (PD) treatment program and he needs a speech therapist; can you help him?” At the time, I was an Assistant Professor on a tenure track in the Department of Speech, Language and Hearing Science University of Colorado-Boulder and the Recording and Research Center in Denver was my primary research lab. I was working diligently to develop a fundable research program which would allow me to study “my current passion”– acoustic analysis of voice in aged individuals and those with neurological diseases.
Of course, I followed Dr. Gould’s advice and met his friend in Estes Park, Colorado at the location of his PD treatment program. It was here that I had my very first encounter with individuals with PD. Shortly thereafter, during one of my monthly trips to Estes Park, I was introduceed to a group of professionals who were developing a PD treatment program in Scottsdale, Arizona. They invited me to visit Scottsdale and to meet the family who was initiating the program in honor of their wife and mother, Mrs. Lee Silverman, who had been diagnosed with PD.
“If only we could hear and understand her” wished Mr. Ray Silverman and his adult children Tom and Carol regarding Mrs. Silverman, when I first met them in Scottsdale. At the time, speech treatment for patients with PD was considered to be unsuccessful. The consensus among the professional communities was “changes in the speech treatment disappear on the way to the parking lot” and while nearly 90% of patients with PD had a speech problem, only 4% received speech treatment.
The Silverman family found their inability to communicate with Mrs. Silverman most difficult. They challenged me to develop a speech treatment to help their mother communicate and invited me to set up a speech treatment program at their newly evolving “Lee Silverman Center for Parkinsons” in Scottsdale. The Lee Silverman Center program was designed to be a month long, daily multi-disciplinary program to include medical care, physical therapy, occupational therapy, speech therapy, family support, nutrition and recreation.
Because the Silverman family was particularly concerned about speech in PD, they agreed to my request to fund a speech research lab within the clinical facility and hired a student of mine (Carolyn Mead Bonitati), a recent graduate of the University of Colorado-Boulder, to be the speech clinician in residence. My role was to design the speech treatment program and collect and analyze once a month pre-, post- and follow-up speech treatment data.
In 1985, the ‘seeds were sown’ for what is known today as Lee Silverman Voice Treatment (LSVT). At the time, most speech treatment approaches for PD focused on the classic articulation and rate problems in these patients. However, since I came from the world of voice, my instinct was to treat the voice disorder which included soft volume, monotone, hoarseness and breathiness. We developed a physiologically-based treatment program that we thought (naively at the time) focused primarily on laryngeal function. Our target was vocal fold adduction as an avenue to improve vocal loudness and quality. In order to motivate patients, we designed the treatment to be a high effort exercise program which combined voice exercises and generalization in to speech production. The treatment was designed to continuously push patients to new vocal effort levels (e.g., “louder, longer”). As a result, patients were highly engaged in physical exercise of their voices for 60 minutes a day within treatment sessions and had daily assignments to use their newly trained louder voice outside of the treatment room. In addition, we recognized that patients had problems with sensory feedback of vocal loudness (they believed the world had developed a hearing loss instead of recognizing that their voice was too soft) so we worked to ‘recalibrate’ the sensory system as well. The first outcome data were impressive and we summarized them in a paper: Ramig, Bonitati, Lemke and Horii, 1994.
Over the years we have advanced our understanding of LSVT LOUD™ and PD. Today we recognize that LSVT LOUD targets amplitude training (increased vocal loudness) as a single motor control parameter. It incorporates: (1) enhancing the voice source, which is consistent with improving the carrier in the classic engineering concept of signal transmission (Titze,1993); (2) using vocal loudness as a trigger for distributed system-wide effects across the speech production system; (3) recalibration of vocal loudness and effort so individuals with PD integrate improved loudness into functional communication; and (4) training the individual to rely on his own resources (internal cueing and self-monitoring) to independently control and sustain adequately scaled speech motor output.
The result is reduction or elimination of hypophonia, hypoprosodia, and hypokinetic articulation characteristics of the dysarthria associated with PD (Sapir, Ramig and Fox, 2008). It is critical to recognize that the loudness target in LSVT LOUD is a healthy increase in vocal loudness. Patients are not trained to ‘yell or scream or to use pressed voice’, rather the speech clinician trains a voice that has improved loudness with healthy voice quality. On the surface, the simplicity of a single, simple over learned treatment target for patients to be “LOUD” may make it feasible for these individuals with cognitive and learning challenges to successfully improve functional speech production in daily living (Fox et al., 2002). Beneath the surface simplicity of the target to be “LOUD”, the speech clinician is delivering a well-integrated training program which is designed to directly address the complexity underlying the speech problem experienced by patients with PD (Sapir et al., 2008).
The LSVT LOUD mode of delivery also differs from traditional forms of speech treatment. It requires intensive, high effort speech exercise combined with a simple, redundant and salient treatment target to facilitate transfer of loudness into functional daily living. The standardized protocol for LSVT LOUD embodies many of the fundamental principles of exercise and motor training that have been shown to promote neural plasticity and brain reorganization in animal models of PD (Fisher et al., 2004) and human strokerelated hemiparesis (Liepert et al., 1998). Our ability to embrace these principles and integrate them into the mode of delivery of treatment will be essential for advancing rehabilitation science in parallel with neuroscience.
While the standardized protocol for LSVT LOUD was developed before these recent neuroscience investigations, it adheres to key principles of neural plasticity (intensity, complexity, saliency, use it or lose it, and use it and improve it) which are likely additional explanations for why LSVT LOUD has been successful (Fox et al., 2006;Farley, Fox, Ramig and McFarland, in press).
LSVT LOUD Pre- and Post-Treatment
June 06, 2012 6:18 pm MDT
Watch the amazing transformation of Shirley – an LSVT LOUD Client!View All