Lsvt 5 Concepts And Techniques

(voice focus, high effort, intensive, sensory calibration, quantification)

Neural

□ SCALING AMPLITUDE

□ SENSORY PROCESSING

Neuropsychology

□ slow thinking

□ slow learning

□ problems sustaining attention

□ problems shifting cognitive set

□ problems internally cueing

□ problems in procedural memory

Neural

□ SCALING AMPLITUDE

□ SENSORY PROCESSING

Motor Learning

□ Sensory Processing

□ Intense Practice

□ Specific context

Muscle Training

□ Progressive resistance

□ Specificity

Compliance and Motivation

Physiologic

Motor Learning

□ Sensory Processing

□ Intense Practice

□ Specific context

Muscle Training

□ Progressive resistance

□ Specificity

Compliance and Motivation

Physiologic

□ Respiratory drive

□ Laryngeal valving (ROM, stability)

□ System-wide effects

"LOUD" (effort, coordination)

FIGURE 2 This figure graphically summarizes the rationale underlying the five essential concepts and techniques of the Lee Silverman Voice Treatment (LSVT®) from a neural, speech mechanism physiology, motor learning, muscle training, neuropsychological, and compliance perspective. The neural bases are the reduction in muscle activation and self-monitoring and consequent problem in programming an output target with adequate amplitude. The physiologic basis is the focus on respiratory drive and laryngeal valving to generate a maximally efficient vocal source. "Loud" is used as the system trigger for improving effort and coordination across the speech mechanism. The LSVT® is administered in a manner consistent with principles of motor learning in order to maximize the treatment effectiveness. Emphasis on sensory processing, increased practice, practice within specific context, and a simple "root" focus (e.g., loud) are key elements of treatment. The neuropsychologic aspects of Parkinson's disease: slow thinking, slow learning, problems sustaining attention, problems shifting cognitive set, problems internally cueing, and problems in procedural memory are also taken into account with the LSVT®. The LSVT® is also administered in a way consistent with muscle training. Treatment technique overloads the muscles using progressive resistance in specific activities. The LSVT is designed to maximize patient compliance. From day 1 of treatment, activities are designed to maximize the impact on daily functional communication. Abbreviations: LSVT, Lee Silverman Voice Treatment.

Furthermore, LSVT® is designed to comply with the principles of motor plasticity training, namely intensive training of motor tasks, increased practice of motor tasks, active engagement in tasks, and the sensory experience of the motor task (116,117). The training should also address the most prominent etiologic factors underlying the behavior to be changed, with the target behavior having a significant ameliorating impact of these etiologic factors. In the case of voice and speech disorders in PD, training should address deficits in internal cueing, sensorimotor gating, scaling amplitude of speech movement patterns, and self-perception and regulation of vocal effort and output (86).

Specifically, the LSVT® uses high effort, but not strenuous, loud phonation to encourage optimal glottic closure and maximum phonatory efficiency. Patients are taken through exercises on a daily basis, repeatedly practicing and emphasizing maximum duration loud phonations, maximum high- and low-pitch phonations, and speech exercises with improved loudness. This improved phonation is then carried over into speech and conversation following a standardized hierarchy, with focus on monitoring the amount of effort required to sustain sufficient vocal loudness ("calibration"). No direct attention is given to speech rate, prosodic pitch inflection, or articulation. Therapy is administered four times per week over four weeks, each session lasting 50 to 60 minutes.

The goal of the LSVT® is to improve functional communication for at least six to 12 months without additional treatment. After 16 sessions of individual treatment, most patients will be able to maintain speech and voice changes for at least six months and sometimes for up to one (4) or two years (15,118) without additional speech treatment. Within the 16 initial sessions of treatment, patients are encouraged to establish a daily homework routine that they maintain on their own once treatment is over. All patients are encouraged to return for a reassessment at six months, at which time some patients may benefit from a few additional sessions. Further details of the LSVT® have been described elsewhere (73).

Treatment data suggest that individuals with mild to moderate PD have the most positive treatment outcomes following the LSVT®. Early administration of the LSVT® or other intensive voice and speech treatment programs is also important, since research shows that the most effective ways to induce neural plasticity and neural protection with behavioral treatment is to apply therapy before neurotoxic-ity and before the degenerative process is severe (116,117,119). Patients with severe PD, severe depression, or severe dementia have a poor prognosis with LSVT®; however, patients with co-occurring mild to moderate depression and dementia can benefit (14). Because treatment focuses on voice, all patients must have a laryngeal examination before treatment to rule out any contraindications (e.g., vocal nodules, gastric reflux, laryngeal cancer). It is important to clarify that the goal of the LSVT® is to maximize phonatory efficiency. It is never the goal to teach "tight or pressed" voice but rather to improve vocal fold adduction for optimum loudness and quality without undue strain.

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