The Science and
Practice of LSVT BIG
Robert B. Leavitt PT, MPT, OCS, JSCC,
LSVT cert.
VP Operations OSPT
Ph: 707-571-7615
osptclinic.com
Copyright LSVT Global, Inc. 2011
www.lsvtglobal.com
Objectives
Explain advances in neuroscience and impact on the
field of rehabilitation
Briefly discuss development and data on an efficacious
speech treatment LSVT LOUD
Describe development and key aspects of limb motor
treatment LSVT BIG
Introduce the LSVT HYBRID approach (simultaneous
delivery of BIG and LOUD)
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It is an exciting time to be in
rehabilitation today!

Basic science evidence for the value of
exercise in PD (classically drugs, surgery,
today…)

Identified key principles of exercise that
drive activity-dependent neural plasticity

Demonstrated that exercise can improve
brain functioning (neural plasticity) and
may slow disease progression

Exercise is Medicine!
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Kliem & Jones, 2008; Ludlow et al, 2008
Legitimate Therapeutic Options
To provide symptomatic relief; improve function
Pharmacological
(L-dopa)
Neurosurgical
(DBS-STN)
Voice and Body
Exercise
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Zigmond et al, 2009
“If only we can hear and understand her”
Family of Mrs. Lee Silverman 1987
5 Stages of Grief
Denial - “There must be some mistake!”
Anger – “I sure got shafted this time.”
Bargaining – “There must be a cure.”
Depression – “This is hopeless.”
Acceptance – “ I can deal with this.”
These stages must be worked through before any
meaningful process can begin.
Source: On Death and Dying. Elizabeth Kubler-Ross
20+ year journey from invention to intervention
Phase IV, V
Phase III
Phase I, II
Over 8 million dollars in NIH funding
1987-89: Initial invention; Pilot data (Scottsdale)
1989-91: Office of Education OE-NIDRR
1991-94: OE-NIDRR
1990-95: NIH funded RCT Efficacy
1995-00: NIH funded EMG, Kinematics
2002-07: NIH funded RCT Spread of effects
2007-12: NIH funded RCT, imaging
2001-02: Coleman Institute (PDA; LSVTC)
2002-04: NIH and M J FOX Foundation PDA (R21)
2002-04: Coleman Institute (VT; LSVTVT)
2004-06: NIH LSVTVT (R21)
2004 : Coleman Institute (LSVT Down Syndrome)
2004-07: LSVT –Dissemination
2006:
Technology-enhanced Clinician Training (SBIR)
2010:
Technology-enhanced LSVT LOUD delivery (SBIR
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LSVT Programs
Administered in an intensive manner to
to challenge the impaired system.
Techniques specific to PD-specific deficits!
bradykinesia/hypokinesia
and
kinesthetic awareness
(sensory deficit)
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TARGET of LSVT LOUD
Loud is more than a laryngeal event
– spread of effects
LOUD
SOFT
Neural coupling (McClean and Tasko)
HEALTHY LOUDNESS
CALIBRATION
Learning
Imaging Studies with LSVT LOUD
Liotti, Ramig, et al, 2003
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LSVT LOUD
LSVT BIG
(Farley & Koshland, 2005; Farley, Fox, et al., 2008;
Farley & Koshland, in revision)
What are the fundamentals of
LSVT BIG?
Standardized, research-based, specific protocol
TARGET: Bigness (amplitude)
MODE: Intensive and High Effort
CALIBRATION: Generalization
Sensory
Internal cueing
Neuropsychological changes
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TARGET
BIG (Large amplitude whole body movement)
Single Target - Triggers Activation across motor systems
SMALL
BIG
NORMAL “BIGNESS“
MODE
Delivery
– Certified LSVT BIG Physical/Occupational
Therapist
• 1:1 intervention
Time of Practice
– 4 consecutive days per week for 4 weeks
– 16 sessions in one month
– 60 minute sessions
– Daily carryover assignments (30 days/entire
month)
– Daily homework (30 days/entire month)
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CALIBRATION
MISMATCH between self-perception
of output and how others perceive it
“I had no idea how small my world had
become”
“I can’t move like this, people will think
I am crazy!!”
CALIBRATION
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Learning
Impaired
self-perception
Deficits in
internal cues
Small movements
reduced
amplitude of output
Goal of LSVT BIG
Mode
Intensive, High effort
(consistent with principles of
neural plasticity)
Target
Calibration
Self-perception,
Internal cues,
Simple, Redundant
Increase Bigness
increase
amplitude of output
Treatment Session
Daily Exercises
1.Floor to Ceiling
2.Side to Side
3.Forward step
4.Sideways step
5.Backward step
6.Forward Rock and Reach
7.Sideways Rock and Reach
Functional Component Tasks
5 EVERYDAY TASKS– 5 reps
each For Example:
-Sit-to-Stand
-Pulling keys out of pocket
-Opening refrigerator door
Walking BIG distance/time may vary
Hierarchy Tasks
Patient identified tasks:
Getting out of bed
Playing golf
In and out of a car
Build complexity across 4 weeks of
treatment towards long term goals
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Daily Whole-body Maximal Amplitude Exercises
Multidirectional Sustained Movements
Floor to Ceiling
Side to Side
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Daily Whole-body Maximal Amplitude
Exercises
Multidirectional Repetitive Movements
Sideways
Backwards
Forwards
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Functional Component TASKS
Functional Components – Patient DRIVEN!
Rolling
Floor to Stand
Getting in or out of bed
Sit to stand
Sit & reach
Stand & reach
Walk & reach
Walk & turn
Stand & turn
Sit to stand BIG
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Daily Hierarchical Tasks
“Real-World” BIG Tasks – Patient DRIVEN!
Examples:
Bed to Bathroom
In/Out of Car
Walk and Talk
Tennis
Chores
Golf
Hiking
Gardening
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Patient case: Bernie
• 71 year-old, diagnosed with Parkinson’s disease
in 1994
• Reason for referral: slowness and difficulty
walking, history of falls, freezing
• Optimized on PD medications
Copyright LSVT Global, Inc. 2011
Objective Outcomes:
PRE
Falls
Assistive device
Confidence
Gait Velocity
% of age matched norm
Endurance
1-2/month
Cane
37.5%
0.35 m/s
29.6 %
730 ft
Copyright LSVT Global, Inc. 2011
POST
0/month
None
56.8%
1.17 m/s
100%
1200 ft
Bernie’s Goals
To improve his walking
To go to the movies
To play with his grandchildren
To go out to dinner with friends and family
All accomplished to his satisfaction!
Copyright LSVT Global, Inc. 2011
LSVT BIG
vs.
Traditional Outpatient Physical Therapy
Randomized Comparative Pilot Study
Matched Frequency/Duration
4X/week for 4 weeks; 1-hour individual sessions
N=42
Hoehn & Yahr 1-3
Intention to treat analysis
Farley & Koshland, in preparation (Unpublished data)
Walking Improvements
Faster
Preferred Stride Length
BIG
12
TRAD
Absolute Change
(cm/sec)
14
Better
10
8
6
4
2
0
T4-T1
1-month
T12-T1
3-months
Absolute Change (cm)
Preferred Velocity
Bigger
14
12
10
8
6
4
2
0
T4-T1
1-month
T12-T1
3-months
Improvements occurred in both groups and lasted 3 months.
Farley & Koshland, in preparation (Unpublished data)
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Trunk Rotation
BIG
Trunk Rotation
TRAD
Absolute Change
Better
30
P < .05
P < .05
25
20
15
10
5
0
T4-T1
-5
1-month
T12-T1
3-months
Only improved for LSVT BIG
Farley & Koshland, in preparation (Unpublished data)
Copyright LSVT Global, Inc. 2011
Conclusions:
• Activity Matters
• LSVT BIG may be especially important for
trunk rotation and balance - everyday
movements
Principles of LSVT applied
simultaneously to the
speech and limb motor systems.
LSVT HYBRID = LOUD + BIG
 Combined or “Hybrid” approach for PD
 May promote greater plasticity through greater
intensity, complexity, saliency
 Enhance practical, logistical, financial costs of
PD rehabilitation
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LSVT HYBRID retrains
“normal use”
“In my normal everyday life,
I just exaggerate my movements.
I keep things Big when
I reach for things,
or when I bend or when I walk;
and when I talk –
I keep my voice strong.”
Copyright LSVT Global, Inc. 2011
Summary
Advances in neuroscience have provided
neurobiological and behavioral evidence supporting the
positive impact of exercise-based protocols in people
with PD
There is a rapidly growing literature in physical
therapy/exercise protocols in humans with PD
LSVT Programs have been developed and studied over
the past 20 years
LSVT BIG is one type of physical therapy program that
has potential to offer improvements in movement and
quality of life for people with PD
Copyright LSVT Global, Inc. 2011
“It is possible to take charge of
your life, even with Parkinson’s.
It is possible for your will
to override your brain.
It is possible to have
Power Over Parkinson’s”
Sharon Kha, LSVT BIG and LSVT LOUD Graduate
“Fear is an emotional “germ” that will destroy
the spirit. Filling your brain with “I can
thoughts” will turn fear away”
“No matter what the reason for it, inactivity is
unhealthy. The less active we are the weaker
we become and the more likely we are to
develop obesity, osteoporosis, diabetes, and
heart disease.”
Source: Take Charge of Your Chronic Pain.
Peter Abaci, MD. Globe Pequot Press.
Thank you for your attention!
Presented by Robert B. Leavitt PT, MPT,
OCS, JSCC
VP Operations OSPT
795 Farmers Lane
Santa Rosa, CA 95405
Ph: 707-571-7615
osptclinic.com
More info available at
www.lsvtglobal.com
Lee Silverman Voice Therapy:
Rehabilitative Therapy for People with
Parkinson’s
Parkinson’s Support Group
January 19th, 2013
Oakmont
Santa Rosa, CA
Presented by:
Dr. Deborah Swain, Ed. D, CCC-SLP
The Swain Center
795 Farmers Lane, Suite 23
Santa Rosa, CA 95405
(707) 575-1468
www.theswaincenter.com
Lee Silverman Voice Therapy
(LSVT®) Introduction
• The LSVT® LOUD improves both the voice and
speech of individuals with Parkinson’s Disease by
treating the underlying physical pathology
associated with the disordered voice
• Treatment focuses on improving vocal loudness
and immediate carryover into daily communication
enabling patients to maintain and/or improve their
oral communication
• The LSVT® LOUD is administered on an intensive
schedule of 16 individual, 60-minute sessions in
one month’s time
LSVT® Introduction
• 90% of patients improve vocal loudness
from pre to post-treatment
• Approximately 80% of patients maintain
treatment improvements in their voice for
12-24 months post-treatment
• ALL patients report improvement in their
ability to communicate
• LSVT® LOUD is being successfully
delivered by over 4,000 certified LSVT®
clinicians in 41 countries
Goal of LSVT®
• Patient uses his or her voice
“automatically” in daily
communication
• There is a carryover of this
information for the long term
Need for LSVT® LOUD
• Few patients with motor speech
disorders receive treatment with welldocumented efficacy
– 89% of patients with Parkinson’s Disease
have disordered speech (Logemann et
al, 1978)
– But only 4% of those individuals receive
treatment (Mutch et al, 1986; Hartelius &
Sveenson, 1994)
Why Treat Phonation in
Neurological Disorders?
• Motor speech disorders accompanying neurological
disorders limit functional oral communication
• Oral communication is a vital element in:
–
–
–
–
Education
Employment
Social functioning
Self expression
• Treatment of one area of speech enhances many
levels of speech production
– Improves capability of treatment
– Simplifies treatment
LSVT® LOUD as a Trigger
• Improves articulation
• Enhances “source” of speech
– Turns up the volume
– Improves vocal fold movements
• Acts as a trigger
– Vocal tract effects
• Reduces spread of effects
Speech Behaviors in
Parkinson’s Disease
• Reduced volume of speech is a
key factor in Parkinson’s Disease
– Patients can sometimes feel like they are
shouting to be heard
• Voice must be stimulated in order to
successfully increase loudness and
enable speech to be heard
Soft Voice Loop
Origins of Speech Disorders
in Parkinson’s Disease
• Motor challenges
• Sensory challenges
• Neuropsychological (cueing)
challenges
Neuropsychological Challenges
• Internally vs. Externally Cued
Movements
– Parkinson’s Disease results in patients being
unable to self-initiate speech
– Deficits in self-initiated movements are due to
an under-activation of Sensory Motor Areas
Perceptual Characteristics
• Reduced loudness
• Hoarse voice quality
• Monotone
• Imprecise articulation
• Vocal tremors
– Some patients report reduced volume, a hoarse
voice or being monotone as the first symptom
on Parkinson’s Disease
• Lowering of functional oral communication
– Less likely to participate in conversations or
have confidence in their voice (Fox and Ramig,
1997)
LSVT® LOUD Impact
• Some responses from LSVT®
LOUD participants:
– “My voice is alive again”
– “I can talk to my grandchildren!”
– “I feel like my old self”
– “I am confident I can communicate!”
LSVT® LOUD Methods
• Assessment
– Separate from 16 sessions of LSVT® LOUD
• Overview
– 4 days a week for 4 weeks (16 sessions in 1 month)
– 50-60 minute sessions
• Integration of five essential concepts
–
–
–
–
–
All focus on voice
All are high effort
All are completed daily
All are tools for calibration
All are quantified
LSVT® LOUD Design
• Designed to allow a patient to
consistently progress to desired
functional speech level
• Designed to help a patient build their
ability and reduce frustration
• Designed to bring voice rescaling back
into speech
• Both vocal loudness level and
calibration are addressed in this
hierarchy
Voice Training with LSVT®
LOUD
• Maximize phonatory efficiency by
increasing loudness – KEY
• Rescale phonatory loudness and
effort
• Voice is #1 priority
• Keep it simple
LSVT® LOUD Work at Home
• Designed to:
– Provide additional practice
– Enable patient to become comfortable with
the use of a high vocal effort
– Establish a routine schedule of practice at
home
• “Brush your teeth – do your ‘Ah’s”
• Methods:
– 5 – 10 minutes one other time on treatment
days
– 10-15 minutes twice daily on non-treatment
days
LSVT® LOUD Post-Treatment
Model
• Practice at home
• Complete treatment tasks
• LSVT® LOUD Homework Helper can be
used at home
• Six months post-treatment:
– Check-in with clinician
– More severe patients may check in earlier
(around two months)
• Patients may end up needing:
– One or two “tune-up sessions”
– Enhanced motivation
– Calibration rescaling
LOUD Crowd
• Following completion of the 4-week program each
patient enters the maintenance phase of the Northern
California Voice Project’s program and becomes a
member of the “LOUD Crowd.”
• Meets the challenge of maintaining the speech and
swallowing gains attained from the intensive Lee
Silverman Voice Therapy program.
• Loud Crowd provides support, encouragement, and
continued care from a certified speech-language
pathologist.
• Patients who participate in continued voice maintenance
have been shown to maintain their improved voices for
more than five years.
LSVT® LOUD Model for
Treatment of Individuals with
Parkinson’s Disease
LSVT® LOUD Model for
Treatment of Individuals with
Parkinson’s Disease
Changes in Vocal Loudness in Individuals
with Parkinson's Disease Following LSVT®
• Ramig, Sapir, et al. (2001)
– This study assessed the impact of the Lee Silverman Voice
Treatment (LSVT®) on vocal loudness (Sound Pressure
Level – SPL) in a group of individuals with Parkinson's
disease
– The individuals treated with LSVT® increased voice vocal
loudness (SPL) from by an average of 8 decibels (dB) and
from baseline to 6 months follow-up by an average of 6 dB
• These changes were statistically significant and perceptibly
audible
– Treated patients showed a significant increase in vocal
loudness (SPL); this was statistically significant for all voice
and speech tasks
• These findings, along with others, provide additional support
for the efficacy of the LSVT®
Questions & Comments