1. The Science and Practice of LSVT BIG
Robert B. Leavitt PT, MPT, OCS, JSCC, LSVT cert.
VP Operations OSPT
Ph:
osptclinic.com
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010

2. 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)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 2

3. 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
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 3

4. Legitimate Therapeutic Options
To provide symptomatic relief; improve function
Neurosurgical
(DBS-STN)
Pharmacological
(L-dopa)
Voice and Body
Exercise
Copyright LSVT Global, Inc. 2011
Zigmond et al, 2009
Fox, C. Presentation, August, 2010 4

5. “If only we can hear and understand her”
Family of Mrs. Lee Silverman 1987
Fox, C. Presentation, August, 2010 5

6. 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

7. Copyright LSVT Global, Inc. 2011
20+ year journey from invention to intervention Over 8 million dollars in NIH funding
: Initial invention; Pilot data (Scottsdale)
: Office of Education OE-NIDRR
: OE-NIDRR
: NIH funded RCT Efficacy
: NIH funded EMG, Kinematics
: NIH funded RCT Spread of effects
: NIH funded RCT, imaging
: Coleman Institute (PDA; LSVTC)
: NIH and M J FOX Foundation PDA (R21)
: Coleman Institute (VT; LSVTVT)
: NIH LSVTVT (R21)
2004 : Coleman Institute (LSVT Down Syndrome)
: LSVT –Dissemination
2006: Technology-enhanced Clinician Training (SBIR)
2010: Technology-enhanced LSVT LOUD delivery (SBIR)
Phase I, II
Phase III
Phase IV, V
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 7

8. bradykinesia/hypokinesia kinesthetic awareness
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)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 8

9. TARGET of LSVT LOUD LOUD SOFT HEALTHY LOUDNESS
Loud is more than a laryngeal event – spread of effects
LOUD
SOFT
HEALTHY LOUDNESS
Neural coupling (McClean and Tasko)
Fox, C. Presentation, August, 2010 9

10. CALIBRATION
Learning
sensory
problem,
internal cueing 10

11. Imaging Studies with LSVT LOUD
Liotti, Ramig, et al, 2003
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 11

12. LSVT LOUD
LSVT BIG
(Farley & Koshland, 2005; Farley, Fox, et al., 2008;
Farley & Koshland, in revision)
Fox, C. Presentation, August, 2010 12

13. 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
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 13

14. TARGET BIG (Large amplitude whole body movement)
Single Target - Triggers Activation across motor systems
SMALL
BIG
NORMAL “BIGNESS“
Fox, C. Presentation, August, 2010 14

15. Copyright LSVT Global, Inc. 2011
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)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 15

16. “I had no idea how small my world had become”
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!!”
Fox, C. Presentation, August, 2010 16

17. normal movement effort and
CALIBRATION
Learning
Retrain sensory
calibration and learn
new internal cues for
normal movement effort and
bigness
Copyright LSVT Global, Inc. 2011
Copyright© LSVT Global, Inc. 2011 17

18. Impaired self-perception Deficits in Small movements internal cues
reduced
amplitude of output
Copyright© LSVT Global, Inc. 2011 18

19. (consistent with principles of neural plasticity)
Goal of LSVT BIG
Mode
Intensive, High effort
(consistent with principles of neural plasticity)
Target
Calibration
Increase Bigness
increase
amplitude of output
Self-perception,
Internal cues,
Simple, Redundant
Fox, C. Presentation, August, 2010 19

20. Copyright LSVT Global, Inc. 2011
Treatment Session
Daily Exercises
Floor to Ceiling
Side to Side
Forward step
Sideways step
Backward step
Forward Rock and Reach
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
Copyright LSVT Global, Inc. 2011

21. Copyright LSVT Global, Inc. 2011
Daily Whole-body Maximal Amplitude Exercises Multidirectional Sustained Movements
Floor to Ceiling
Side to Side
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 21

22. Copyright LSVT Global, Inc. 2011
Daily Whole-body Maximal Amplitude Exercises Multidirectional Repetitive Movements
Sideways
Backwards
Forwards
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 22

23. Copyright LSVT Global, Inc. 2011
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
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 23

24. Copyright LSVT Global, Inc. 2011
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
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 24

25. Copyright LSVT Global, Inc. 2011
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
Fox, C. Presentation, August, 2010 25

26. Copyright LSVT Global, Inc. 2011
Objective Outcomes:
PRE
POST
Falls /month 0/month
Assistive device Cane None
Confidence % %
Gait Velocity m/s m/s
% of age matched norm % 100%
Endurance ft ft
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 26

27. Copyright LSVT Global, Inc. 2011
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
Fox, C. Presentation, August, 2010 27

28. Traditional Outpatient Physical Therapy
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)
Fox, C. Presentation, August, 2010 28

29. Walking Improvements Better Faster Bigger
TRAD
Better
1-month
3-months
1-month
3-months
Improvements occurred in both groups and lasted 3 months.
Farley & Koshland, in preparation (Unpublished data)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 29

30. Copyright LSVT Global, Inc. 2011
Trunk Rotation
TRAD
BIG
Better
1-month
3-months
Only improved for LSVT BIG
Farley & Koshland, in preparation (Unpublished data)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 30

31. Conclusions: Activity Matters LSVT BIG may be especially important for
trunk rotation and balance - everyday movements
Fox, C. Presentation, August, 2010 31

32. Copyright LSVT Global, Inc. 2011
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
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 32

33. 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
Fox, C. Presentation, August, 2010 33

34. 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
Fox, C. Presentation, August, 2010 34

35. “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 35

36. “Fear is an emotional “germ” that will destroy the spirit
“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.

37. Presented by Robert B. Leavitt PT, MPT, OCS, JSCC
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:
osptclinic.com
More info available at

38. Parkinson’s Support Group
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)

39. 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

40. LSVT® Introduction
90% of patients improve vocal loudness from pre to post-treatment
Approximately 80% of patients maintain treatment improvements in their voice for 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

41. Goal of LSVT®
Patient uses his or her voice “automatically” in daily communication
There is a carryover of this information for the long term

42. Need 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)

43. 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

44. 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

45. 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

46. Soft Voice Loop

47. Origins of Speech Disorders in Parkinson’s Disease
Motor challenges
Sensory challenges
Neuropsychological (cueing) challenges

48. 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

49. 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)

50. 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!”

51. LSVT® LOUD Methods Assessment Overview
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

52. 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

53. Voice Training with LSVT® LOUD
Maximize phonatory efficiency by increasing loudness – KEY
Rescale phonatory loudness and effort
Voice is #1 priority
Keep it simple

54. LSVT® LOUD Work at Home Methods: 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

55. 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

56. 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.

57. LSVT® LOUD Model for Treatment of Individuals with Parkinson’s Disease

58. LSVT® LOUD Model for Treatment of Individuals with Parkinson’s Disease

59. 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®

60. Questions & Comments