Description of Method:
The Lee Silverman Voice Treatment program is geared mostly towards individuals with Parkinson’s disease. As individuals with Parkinson’s Disease (PD) often experience difficulties communicating to others due to voice and possible speech problems associated with the disease. Some of these deficits are also apparent in other individuals with other possible diseases. These deficits come in form of low speech volume, vocal hoarseness, breathy vocal quality and poor articulation (Duffy, 2005). When an individual begins to lose their abilities to communicate verbally with others they lose their confidence in communication. As time goes on communication can begin to deteriorate and individuals suffering with PD become more isolated from their social environment. The program of LSVT has been proven to be extremely effective in improving voice and speech problems of individuals suffering with PD or other neurological diseases such as Multiple Sclerosis, Strokes, Ataxia, Cerebral Palsy and Down Syndrome. The treatment program LSVT, was developed by two speech language pathologists with the objective to concentrate on a patients’ attention on increasing voice volume through a rigorous set of exercises. In turn, the other deficits in voice and speech that an individual might have will improve as well through this intensive program. The LSVT program is an intensive one month treatment program consisting of 16 sessions (four times per week) that focus on increasing vocal loudness through the application of motor techniques. In addition to the treatment sessions, the patients following the program must also complete daily homework tasks. During each session, the patients are taught to focus their efforts in increasing their voice volume and to “think loud”. This incorporates sensory awareness training to help these individuals recognize that their voice is too soft, convincing them that the louder voice is within normal limits, and help them adjust to their new louder voice. Patients are also trained to self-generate the sufficient amount of loudness to make their speech understood.
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From a clinician’s Perspective:
From a clinician’s perspective LSVT appears to be one of the most effective therapy programs that has ever been researched. The program has level one clinical evidence which isn’t common with other clinically proven therapy programs. M. Levy who is a certified LSVT therapist has documented the before and after of Parkinson’s disease patients and revealed to a group of clinicians the effectiveness of this program over the course of one month. She also pointed out the different pros and cons that can arise when using the LSVT program.
The advantages to a clinician are that when administering the LSVT one follows a specific protocol which allows less room for a clinician to make mistakes and not provide quality therapy. Each clinician must be properly trained before following the program. LSVT can also be administered in any setting and does not require the usage of any major technical equipment or costly therapy materials. Another factor is that the outcome results of an individual’s voice will last up to two years after.
The disadvantages are that it is a very intense program and requires a lot of effort and motivation from a client. If the client does not attend all sessions and follow up with the homework etc… the program may not be effective as it should be. The clinician cannot adapt the program to a client’s needs as much as one would with other therapy programs because it follows very specific guidelines.
From a client’s perspective:
From a client’s perspective the LSVT program is a rewarding program, as clients see the difference after only one month. Clients have declared that after attending the program they feel themselves again having their voice back. Their self confidence is restored and communication partners can now understand them better (Ramig,1995). Also the program is safe, noninvasive and there are no risks involved which is advantageous to an individual who has a disease such as Parkinson’s.
But, not all patients can sustain the prolonged and intense effort required in the program. Patients who have cognitive impairments may have difficulty conforming to all of the instructions during training. Some may feel even more frustrated from having difficulty following the program and attending each of the sessions during each week.
Tamar Jacob
Part 3 EBP project
Article 1:
Citation:
Ramig, L.O., Sapir, et al., (2001). Intensive voice treatment (LSVT) for patients with Parkinson’s disease: a 2 year follow up. Journal of Neurology, Neurosurgery, and Psychiatry, 71, 493-498.
Summary:
The objective in this research article was to assess long term (24 months) effects of the Lee Silverman voice treatment (LSVT). The LSVT program is to improve Parkinson’s disease patient’s voice function. Thirty three patients with idiopathic Parkinson disease were randomly chosen and assigned to two treatment groups. The first group received the LSVT focusing on high phonatory-respiratory effort. The second group received respiratory therapy (RET), which only focused on respiratory effort, Patients in each treatment group were instructed to sustain vowel phonation, read a passage and to produce a monologue under similar conditions before, right after, and 24 months after received treatment. They used acoustic analyses of voice loudness (measured as sound pressure level) and inflection in voice fundamental frequency (measured in terms of semitone standard deviation) to measure the changes in their vocal function. The results revealed that LSVT was significantly more effective that the RET in improve the sound pressure level and STSD right after treatment and maintained up to years later. This provides clear evidence for the effectiveness of the LSVT post-treatment and long term maintenance to increase phonation to higher intensity level. More research is necessary to determine the effects of the LSVT on improving vocal quality, prosody, articulation, intelligibility, and swallowing.
Level of Study: I
Grade/Recommendation: B
Article 2:
Citation: Spielman, J. Ramig, L. O., Mahler, L., Halpern, A. & Gavin, W. J. (2007). Effects of an extended version of the Lee Silverman Voice Treatment on voice and speech in Parkinson’s disease. American Journal of Speech-Language Pathology, 16, 95 -107.
Summary:
The purpose of the research article is to examine voice sound pressure level (SPL), voice handicap and speech characteristics following an extended version of the Lee Silverman voice treatment in order to determine if current treatment dosages can be changed without compromising clinical outcomes.
The study was conducted with twelve participants who have idiopathic Parkinson’s disease. They received the extended treatment version (LSVT-X), which is similar to LSVT except it was administered twice a week in 1 hour sessions of 8 weeks and required more homework. Recording were made in a sound-treated booth pre and post treatment and then again 6 months later. Vocal SPL was measured for four different tasks such as reading a passage and then it was compared with data from a previous study, in which the traditional LSVT was administered four times a week for weeks to Parkinson’s disease patients as well. Listener ratings were conducted with audio samples from both of the studies, using sentence pairs from a standard passage. The patients who received the LSVT-X also completed the Voice Handicap Index (VHI) before the recordings. The results showed that the patients who followed through with the LSVT-X increased their vocal SLP by 8 dB after treatment and maintained an increase of 7.2 dB in vocal SLP at 6 months. The VHI scores improved for 25% of the participants right after treatment, and the listener ratings revealed audible improvement in their speech. This shows evidence of the LSVT-X program increasing SPL, decreasing perceived voice handicap and improving their functional speech. Further large-scale research is needed to establish solid evidence and efficacy of the LSVT-X program.
Level of Study: Level I
Grade/Recommendation: B
Article 3:
Citation: Sharkawi, A.E. et al., (2002). Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study. Journal of Neurology, Neurosurgery, and Psychiatry, 72, 31-36.
Summary:
The objective in this study is to define the effects of the Lee Silverman Voice Treatment on swallowing and voice in eight patients with idiopathic Parkinson’s disease. Each patient was administered a modified barium swallow (MBS) as well as a voice recording before and after one intensive month of traditional LSVT. Temporal measures of the swallow were completed and swallowing motility disorders were defined through the MBS. The voice was evaluated through measures of vocal intensity, fundamental frequency and the patient’s perception of their speech change. The results were as follows: The most recurrent swallowing motility disorders before the LSVT was administered were oral phase problems including reduced tongue control and strength. In the pharyngeal stage of swallow, reduced tongue base retraction which resulted in residue in the valleculae was the most common disorder. Oral transit time and pharyngeal transit time were delayed. After they followed through with LSVT there was an overall 51% reduction in the number of swallowing motility disorders. The approximate amount of oral residue after 3 ml and 5 ml liquid swallows was reduced as were some temporal measures of the swallowing such as oral transit time. Vocal intensity was extensively increased as well during sustained vowel phonation and reading. LSVT showed evidence to improve the neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue base function during the oral and pharyngeal phases of swallowing and improving vocal intensity as well. But there was a lack of consistent correlation between degree of improvement of voice and in swallowing as an effect of LSVT. This emphasizes the need for a global measure of speech function that would include parameters representing articulation, prosody, and voice. Further studies of the effects of LSVT on swallowing, voice, and speech are necessary and long term follow up inquiry of these effects.
Level of Study: Level I
Grade/Recommendation: C
Tamar Jacob
Part 4 EBP
Hypothesis
LSVT is an effective treatment program for patients with Dysarthria due to Parkinson’s disease.
Null Hypothesis
LSVt is not an effective treatment program for patients with Dysarthria due to Parkinson’s disease.
Research Design/Methodology
Subjects
100 subjects will be selected at random to gather a sample group. This will include individuals between the age of 55 and 75 with Dysarthria secondary to Parkinson’s disease. Each individual is required to have attended therapy for 6 months to a year prior this program. Participants will be selected through various rehabilitation centers.
Materials
Recording devices and materials, Voice Handicap Index
Procedures
The participants will be randomly divided into two groups. The first group (group A) will go through the LSVT program for one month, 4 sessions a week. The second group will receive voice and respiration therapy 4 times a week for one month. Sample voice recordings will be taken pre and post treatment for each member or each group. Each participant will complete the Voice Handicap Index before beginning intervention. Listener ratings will be completed before and after administration of the treatment program.
Statistical Analysis
A Special ANOVA for two groups repeated measures will be used to determine if there is a difference between the improvement in the intelligibility of patients receiving LSVT and the patients receiving voice and respiration therapy.
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