Breakthrough vocal treatment: 3 practical strategies for success

By 15 November, 2016 No Comments

Part of the Vivir Healthcare’s ‘orange-paper’ series.

Qingwen Loo is a speech pathologist specialising in aged care working with Vivir Healthcare. As part of her professional development with Vivir, Qingwen recently completed the LSVT LOUD online course. These are part of her learnings.

Frustrated with my inability to help an elderly patient with her soft voice as a result of Parkinson’s, especially after watching her break down over our skype treatment session, I decided to do the Lee Silverman Voice Treatment (LSVT) LOUD online course.

It didn’t take long for me to become convinced why LSVT is currently the only treatment with Level 1 evidence available for people with Parkinson’s. The videos that were shown as part of the course blew me away. Whilst not all patients achieve the same level of success, particularly those with more severe symptoms such as Parkinson-Plus Syndromes and multi system atrophy; they were all able to achieve a level of communication that was functional for them. As a clinician, being able to return some sort of function to a person is the greatest reward of all.

So what is LSVT and how can it help?

In a nutshell, the LSVT protocol makes use of motor learning principles, which we know aids neural plasticity. This then not only improves brain function, but may even slow the progression of disease.

The LSVT program aims to increase vocal loudness through three strategies:

  1. Target: vocal loudness

Studies have shown a ‘spreading of effects’ with one simple focus, thinking LOUD. Not only does vocal loudness improve, but so does articulation and speech rate, which can reduce palilalia, a symptom which can appear in the later stages of Parkinson’s. There is also exciting new data suggesting that swallowing improves vocal loudness as well (Sharkawi et al., 2002).

  1. Mode: intensive and high effort

Because practice makes perfect, intensity is the name of the game. LSVT is delivered on four consecutive days a week for four weeks, with each session an hour long. There are daily homework tasks and carryover exercises for all 30 days of a treatment month. This takes commitment from both the client and the clinician.

  1. Calibration: generalisation

Due to the sensory difficulties, reduction in internal cueing and neuropsychological problems that accompany Parkinson’s, achievement of this step ensures success of treatment. This happens when patients are able to automatically use their louder voice outside of the therapy room in their daily communication. When calibrated, studies have shown that effects last for up to two years post-treatment (Ramig et al., 2001). It is good practice to follow-up with clients after six months post-treatment and provide them with the support when they need it.

Given the proven success of the LSVT protocol for people with idiopathic Parkinson’s, the future opportunities for this treatment are endless and exciting. Currently, work is being done to align the fields of Speech Pathology, Occupational Therapy and Physiotherapy (LSVT HYBRID) to not only increase vocal loudness, but also to increase the amplitude of movements.

In addition, attention has been turned to using LSVT with different populations—adults with motor speech disorders and even children with Down Syndrome and Multiple Sclerosis! The early data for these projects seems promising, and I am following the findings of this research closely.

Clinically, since completing the course, I have applied these principles with a client experiencing aphasia, dysarthria and apraxia, as a result of a stroke. Despite it being early days, the practise of maximum duration sustained phonation (aka the ‘ah’) with a focus on LOUD, does seem to improve his breath support and articulation.

I’m now looking optimistically for the right opportunity to use the LSVT protocol in its entirety. Who knew that a simple thought of thinking LOUD could bring about so many positive changes to a person’s life?

Qingwen Loo, Speech Pathologist, Vivir Healthcare


El Sharkawi, A., Ramig, L., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Smith, C. H., … & Werner, C. (2002). Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT®): a pilot study. Journal of Neurology, Neurosurgery & Psychiatry72(1), 31-36.
Ramig, L., Sapir, S., Countryman S., Pawlas, A., O’Brien, C., Hoehn, M., & Thompson, L. (2001). Intensive voice treatment (LSVT®) for individuals with Parkinson disease: A two-year follow-up. Journal of Neurology, Neurosurgery, and Psychiatry, 71, 493-498.