Tips for Speech Therapy for Parkinson's Disease from the Guru of LSVT
Who is Lorraine Ramig?
Dr. Lori Ramig is Chief Scientific Officer of LSVT Global and pioneered the Lee Silverman Voice Treatment (LSVT) for persons with Parkinson disease. She has spent 25 years of research to support the development and implementation of this widely known speech training program for Parkinson’s. She received her doctorate from Purdue University and has been Professor in the Department of Speech, Language and Hearing Science at the University of Colorado-Boulder, Senior Scientist at the National Center for Voice and Speech in Denver, and Adjunct Professor at Columbia University. We sat down with Lori to pick her brain about LSVT.
1. What is LSVT LOUD?
Nearly 90% of persons with Parkinson’s (PWP) have speech and voice disorders. Most of these issues have historically been resistant to medical and to many traditional speech treatments.
LSVT LOUD ® was developed by me and by my colleagues to address this gap in the field. This approach was the first speech treatment which was shown by studies to have effectiveness in improving speech and voice disorders in persons with Parkinson’s.
LSVT LOUD is an intensive, personalized, one-on-one treatment delivered by trained and certified speech-language pathologists. A typical course of treatment has been over one approximately one month’s time. Here are some of the key points for people considering this approach:
One-hour sessions
Four sessions per week
Four consecutive weeks
Daily homework and carryover exercises to promote independence with functional conversation(s) focused on a person’s “real world”
LSVT LOUD incorporates key principles of exercise (e.g. intensity, repetition, salience, complexity) which are consistent with principles of motor learning. It is our belief that LSVT drives activity-dependent neural plasticity and we have been working on research to support this notion. We believe in the principle that ntensity is a benefit which results in internally driven and long lasting change.
LSVT LOUD comprises three key components:
Target (Vocal Loudness): By focusing on healthy vocal loudness we are able to: 1) make coordinated changes across the entire speech production system, and 2) reduce the cognitive load for PWP; since we focus on loudness this helps us achieve our goal.
Mode (Intensive Dosage and High Effort): This mode of delivery encourages PWP to achieve more by working harder. The tasks and readings chosen are salient and tailored to each individual to keep PWP engaged and motivated while working toward their long-term goals.
Calibration (Generalization of improved voice/speech into everyday living): “Recalibrating” the sensory deficits in PWP is critical to help these individuals recognize that their new, louder voice is within normal limits. This recalibrating increases the likelihood that PWP will use their louder voice outside of treatment and that this louder voice will hopefully last over time.
At the conclusion of treatment, it is important to keep practicing your louder voice to maintain the gains achieved through LSVT LOUD. In addition to continued daily homework practice, I encourage LSVT LOUD graduates to consider attending LOUD for LIFE classes in their community. LOUD for LIFE is a group exercise class which provides the opportunity for people who have completed LSVT LOUD to practice their exercises and to share their louder voices in a group setting. The classes are designed to be fun, challenging, and motivating, and to facilitate social interaction while practicing with the new, louder voice. You can search for LOUD for LIFE clinicians to find a group leader in your area.
2. What research advances have been made as a
result of LSVT Loud that are you proud of?
I am proud of our collaborative team who has over 2 decades (plus) published important research in this area of study. Here are some highlights:
Over 8 million dollars in funding from the National Institutes of Health (NIH) supporting research in this area.
There are four large randomized control trials as well as numerous other pre-post and follow-up studies on well over one hundred PWP.
Results from these studies demonstrate positive treatment effects after one month of treatment and some of these effects last for two years.
Research suggests also improvements in articulation, respiration, vocal fold function, and intelligibility. There may be a positive impact on facial expression, swallowing and brain function (PET imaging) though more studies are needed in these areas.
There are studies in other disease populations beyond PWPs.
LSVT LOUD focuses on conversational speech, which is an indicator of a positive impact on functional daily communication.
Link to studies on LSVT: https://blog.lsvtglobal.com/research/
LSVT Global has also developed a software program, the LSVT Companion System, to help individuals practice their LSVT LOUD exercises at home during and after treatment with an LSVT LOUD Certified Clinician. The LSVT Companion System guides individuals through the treatment exercises, while providing audio and visual feedback, and it also collects data on the exercises to share with a client’s LSVT LOUD Certified Clinician. The LSVT Companion System can either be used to allow a PWP to independently progress through some of their LSVT LOUD treatment sessions or to complete home practice during and after treatment for clinician monitoring. Research shows that PWP who used the LSVT Companion for approximately seven of 16 LSVT LOUD treatment sessions had comparable outcomes to those who completed all 16 sessions face-to-face with a clinician. The LSVT Companion is the only solution of its type cleared by the FDA for use as a medical device. Visit https://www.lsvtglobal.com/LSVTCompanion for more information.
3. Can you do LSVT LOUD virtually?
Yes, I am proud to say especially during the pandemic that! LSVT LOUD can be conducted via tele-practice. We have some evidence to support this mode of delivery from researchers within and outside of our LSVT Global team. Research studies so far demonstrate that LSVT LOUD which was delivered via tele-practice was as effective as LSVT LOUD delivered face-to-face.
4. Do you have any practical tips to improve the
voice?
The most commonly reported voice and speech issues reported for persons with Parkinson’s are:
soft voice
hoarseness
monotone
mumbled speech
rapid speech
Additionally, PD also effects communication because it includes a sensory deficit which makes it difficult for individuals with PD to realize they are speaking too softly. Therefore, when they are asked to speak louder they feel like they are shouting. The following are some recommendations that PWP can implement:
Increase vocal loudness (but do not shout or yell). Speak as if you are trying to be heard over background noise, even if you are in a quiet environment.
· Make eye contact with your communication partner and get closer to them if necessary
· Choose a quiet environment for conversations
· Eliminate distractions or background noise, such as a television
· Use personal amplification devices, particularly if speaking to an audience in a large room
Care partners: We recommend that you have patience as persons with Parkinson’s are not intentionally trying to speak quietly – it is a symptom of PD. The person with Parkinson’s is frequently unaware that they are speaking “too quietly.”
5. What is Project Euphonia?
LSVT Global is partnering with Google on an exciting project!
Project Euphonia aims to improve automatic speech recognition software for people with speech impairments.
These speech impairments may make using devices like Siri, Alexa, or others very frustrating.
Project Euphonia's and ALS was recently covered on the Today Show.
Click here to view a brochure with more information regarding this project
More information is available at project.euphononia@lsvtglobal.com.
To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonBedside and https://www.tourettetreatment.com/
He also serves as the Medical Director for the Parkinson’s Foundation.
To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.