The Lee Silverman Voice Treatment

"The Lee Silverman Voice Treatment program was developed by speech language pathologists, Lorraine Olson Ramig, Ph.D., CCC-SLP, and Carolyn Mead, M.A., CCC-SLP, in 1987. It was named for one of the first patients to receive this treatment. It began as a treatment program for Parkinson disease, and now includes other neurological disorders. This effective voice treatment program is an intensive, behavioral treatment given in sixteen sessions in one month. The techniques are intended to help patients with Parkinson and other neurological disorders increase intelligibility and vocal loudness. Approximately 80% of all patients with Parkinson disease exhibit reduced loudness, unclear speech, monotone, vocal tremor, hoarseness, and rapid rate of speech. The assumption behind this approach to behavioral treatment of neurological disorders is that modification or compensation for underlying laryngeal dysfunction include problems with vocal fold adduction and generation of a stable voice" (Ramig, 1995).

The Lee Silverman Voice Treatment (LSVT) consists of the following five essential concepts:

Concept 1: focus on VOICE

1. Increase/improve vocal fold adduction

2. Maximum impact on intelligibility

3. Immediate reinforcement

4. Simple: "THINK LOUD/THINK SHOUT"

Concept 2: focus on HIGH EFFORT (Phonatory and Physical)

1. Patient rationale

1. Overrides rigidity and hypokinesia by pushing patients to new effort levels
2. Trains new target (rescale amplitude of motor output) by putting the "load on the larynx."
3. Dealing with a progressive neurological disease

2. Clinician rationale

1. Clinician effort equals patient effort (scaling)
2. Lack of affect and physical condition of patient
3. Tendency to be reactive

Concept 3: focus on INTENSIVE TREATMENT (16 sessions of individual treatment
    in one month)

1. Daily opportunity to practice increases likelihood of "building daily increments
    of vocal effort."

2. Maintain motivation and accountability

3. Maximize habituation and carry over

4. Provides an opportunity for the clinician to see the patient's daily fluctuations

Concept 4: focus on CALIBRATION

1. Definition: The patient "knows" and "accepts" the amount of effort needed
    to consistently increase vocal loudness to a level that is within normal
    limits. As a result, the relationship between increased
    vocal effort and vocal output is established. When a patient
    is calibrated, she uses her louder voice "automatically" in her daily
    communication and is able to maintain this louder voice

2. Problem scaling amplitude of motor output related to the voice

3. Need to have "knowledge of results"

4. Convince patient that loud/strong voice is WNL

5. Habituation and carry over

Concept 5: QUANTIFICATION

1. Key to motivate patient / provide feedback

2. Objective methods to document improvement

3. Previous speech treatment ineffective / document efficacy

4. Reimbursement, referrals, and ethics

OVERVIEW OF METHODS

1. Daily variables

2. Hierarchial speech loudness drills

3. Integration of the five essential concepts

1. all focus on voice
2. all are high effort
3. all are completed daily
4. all are tools for calibration
5. all are quantified

4. Actual techniques are common voice treatment approaches (Froeschels,
    Aronson, Boone, Stemple), but this program emphasizes administration and
    integration of techniques specifically designed for voice and speech disorders
    associated with Parkinson disease.

References

Ramig, L.O. (1995). Voice therapy for neurologic disease. Otolaryngology & Head
    and Neck Surgery, 3, 174 - 182.

Ramig, L.O., Countryman, S., Pawlas, A.A., & Fox, C. (1995). Voice treatment
    for Parkinson disease and other neurologic disorders.
    American Speech-Language-Hearing Association.

Gail Herndon, 1997