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

The Science and Practice of LSVT BIG

Robert B. Leavitt PT, MPT, OCS, JSCC, LSVT cert.

VP Operations OSPTPh: 707-571-7615osptclinic.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)


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! Kliem & Jones, 2008; Ludlow et al, 2008


Legitimate Therapeutic OptionsTo provide symptomatic relief; improve function

Pharmacological(L-dopa)

Voice and Body Exercise

Neurosurgical(DBS-STN)

Zigmond et al, 2009Copyright LSVT Global, Inc. 2011

“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 Over 8 million dollars in NIH funding

1987-89: Initial invention; Pilot data (Scottsdale)1989-91: Office of Education OE-NIDRR

1991-94: OE-NIDRR1990-95: NIH funded RCT Efficacy1995-00: NIH funded EMG, Kinematics2002-07: NIH funded RCT Spread of effects2007-12: 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 –Dissemination2006: Technology-enhanced Clinician Training (SBIR)2010: Technology-enhanced LSVT LOUD delivery (SBIR)

Ph

ase

I, II

Ph

ase

III

Ph

ase

IV, V


Administered in an intensive manner to

to challenge the impaired system.

Techniques specific to PD-specific deficits!bradykinesia/hypokinesia

and kinesthetic awareness

(sensory deficit)

LSVT Programs


SOFT

LOUD

HEALTHY LOUDNESSNeural coupling (McClean and Tasko)

Loud is more than a laryngeal event – spread of effects

TARGET of LSVT LOUD

sensory

problem,

internal cueing

LearningCALIBRATION

Imaging Studies with LSVT LOUD

Liotti, Ramig, et al, 2003


LSVT LOUD LSVT BIG

(Farley & Koshland, 2005; Farley, Fox, et al., 2008; Farley & Koshland, in revision)

What are the fundamentals of LSVT BIG?

TARGET: Bigness (amplitude)

MODE: Intensive and High Effort

CALIBRATION: GeneralizationSensoryInternal cueingNeuropsychological changes

Standardized, research-based, specific protocol


BIG (Large amplitude whole body movement)Single Target - Triggers Activation across motor systems

SMALLBIG

NORMAL “BIGNESS“

TARGET

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)

MODE


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

Retrain sensory

calibration and learn

new internal cues for

normal movement effort and

bigness

CALIBRATION

Learning


Impairedself-perception

Small movements

reducedamplitude of output

Deficits in internal cues

Increase Bigness

increaseamplitude of output

Self-perception,Internal cues,

Simple, Redundant

ModeIntensive, High effort(consistent with principles of neural

plasticity)

TargetCalibration

Goal of LSVT BIG

Treatment SessionDaily Exercises1.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 TasksPatient 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


Daily Whole-body Maximal Amplitude Exercises Multidirectional Sustained Movements

Floor to Ceiling Side to Side


Daily Whole-body Maximal Amplitude Exercises

Multidirectional Repetitive Movements

Forwards

SidewaysBackwards


Rolling

Floor to Stand

Getting in or out of bed

Sit to stand

Sit & reach

Stand & reach

Walk & reach

Walk & turn

Stand & turn

Functional Component TASKS

Functional Components – Patient DRIVEN!

Sit to stand BIG


Daily Hierarchical Tasks

“Real-World” BIG Tasks – Patient DRIVEN!

Examples:

Bed to BathroomIn/Out of CarWalk and TalkTennisChoresGolfHikingGardening


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


Objective Outcomes:

Falls 1-2/month 0/month

Assistive device Cane None

Confidence 37.5% 56.8%

Gait Velocity 0.35 m/s 1.17 m/s

% of age matched norm 29.6 % 100%

Endurance 730 ft 1200 ft

PRE POST


Bernie’s Goals

To improve his walkingTo go to the moviesTo play with his grandchildrenTo go out to dinner with friends and family

All accomplished to his satisfaction!


Randomized Comparative Pilot StudyMatched Frequency/Duration

4X/week for 4 weeks; 1-hour individual sessionsN=42

Hoehn & Yahr 1-3

Intention to treat analysisFarley & Koshland, in preparation (Unpublished data)

LSVT BIG vs.

Traditional Outpatient Physical Therapy

Walking Improvements

Farley & Koshland, in preparation (Unpublished data)

Improvements occurred in both groups and lasted 3 months.

TRAD

BIG

Faster Bigger

3-months 3-months1-month 1-month


Trunk Rotation

Farley & Koshland, in preparation (Unpublished data)

Only improved for LSVT BIG

TRAD

BIG

3-months1-month


• Activity Matters

• LSVT BIG may be especially important for trunk rotation and balance - everyday

movements

Conclusions:

Principles of LSVT applied simultaneously to the

speech and limb motor systems.

Combined or “Hybrid” approach for PD May promote greater plasticity through greater intensity,

complexity, saliency Enhance practical, logistical, financial costs of PD

rehabilitation

LSVT HYBRID = LOUD + BIG


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

SummaryAdvances 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


“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 OSPT795 Farmers Lane

Santa Rosa, CA 95405Ph: 707-571-7615

osptclinic.com

More info available at

www.lsvtglobal.com

http://www.lsvtglobal.com/

Lee Silverman Voice Therapy: Lee Silverman Voice Therapy: Rehabilitative Therapy for People with Rehabilitative Therapy for People with

Parkinson’sParkinson’s

Parkinson’s Support GroupJanuary 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 Lee Silverman Voice Therapy (LSVT®)(LSVT®) IntroductionIntroduction

• 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® IntroductionLSVT® 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®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® LOUDNeed for LSVT® LOUD

• Few patients with motor speech disorders receive treatment with well-documented 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 Why Treat Phonation in Neurological Disorders?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 TriggerLSVT® 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 Speech Behaviors in Parkinson’s DiseaseParkinson’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 LoopSoft Voice Loop

Origins of Speech Disorders Origins of Speech Disorders in Parkinson’s Diseasein Parkinson’s Disease

• Motor challenges

• Sensory challenges

• Neuropsychological (cueing) challenges

Neuropsychological ChallengesNeuropsychological 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 CharacteristicsPerceptual 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 ImpactLSVT® LOUD Impact

• Some responses from LSVT® LSVT® LOUD participants: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 MethodsLSVT® LOUD Methods• Assessment

– Separate from 16 sessions of LSVT® LOUD LSVT® LOUD

• OverviewOverview– 4 days a week for 4 weeks (16 sessions in 1 month)4 days a week for 4 weeks (16 sessions in 1 month)

– 50-60 minute sessions50-60 minute sessions

• Integration of five essential conceptsIntegration of five essential concepts– All focus on All focus on voicevoice

– All are All are high efforthigh effort

– All are completed All are completed dailydaily

– All are tools for All are tools for calibrationcalibration

– All are All are quantifiedquantified

LSVT® LOUD DesignLSVT® 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® Voice Training with LSVT® LOUDLOUD

• Maximize phonatory efficiency by increasing loudness – KEY

• Rescale phonatory loudness and effort

• Voice is #1 priority• Keep it simple

LSVT® LOUD Work at HomeLSVT® 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 LSVT® LOUD Post-Treatment ModelModel

• Practice at home• Complete treatment tasks• LSVT® LOUD Homework Helper can be LSVT® LOUD Homework Helper can be

used at homeused at home• Six months post-treatment:Six months post-treatment:

– Check-in with clinicianCheck-in with clinician– More severe patients may check in earlier More severe patients may check in earlier

(around two months)(around two months)• Patients may end up needing:Patients may end up needing:

– One or two “tune-up sessions”One or two “tune-up sessions”– Enhanced motivationEnhanced motivation– Calibration rescalingCalibration rescaling

LOUD CrowdLOUD 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 LSVT® LOUD Model for Treatment of Individuals with Treatment of Individuals with

Parkinson’s DiseaseParkinson’s Disease

LSVT® LOUD Model for LSVT® LOUD Model for Treatment of Individuals with Treatment of Individuals with

Parkinson’s DiseaseParkinson’s Disease

Changes in Vocal Loudness in Individuals Changes in Vocal Loudness in Individuals with Parkinson's Disease Following LSVT®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 & CommentsQuestions & Comments

Documents

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