Say It Loud: NIDCD Grantee's Innovative Voice Treatment Gives People with Parkinson's Disease a Voice

Dr. Lorraine Olson Ramig

Lorraine Olson Ramig, Ph.D., has been telling her patients to speak up for the past 15 years. But her hearing is fine.

Ramig and her colleagues are using a behavioral treatment for people with Parkinson's disease (PD) who have an accompanying voice disorder. A professor in the department of speech, language, and hearing sciences at the University of Colorado at Boulder and a senior scientist at the National Center for Voice and Speech in Denver, Ramig asserts that by speaking more loudly, individuals with PD will gain control of their speech and improve their ability to communicate with others. More than 75 percent of individuals with PD have voice and speech disorders, yet historically, only three to four percent receive any type of speech therapy and an even smaller percentage of these individuals are successful at improving their speech over the long run.

Ramig hopes to change that statistic. An NIDCD grantee, she and her colleagues are the developers of the Lee Silverman Voice Treatment (LSVT) program, an approach designed specifically to address the challenges faced by people with PD who also have voice disorders. She knows too well what these individuals face. "Many of my PD patients with voice disorders speak with a soft, breathy, hoarse voice and have reduced loudness and imprecise articulation, all of which affect speech intelligibility and oral communication."

PD affects about 1.5 million Americans and belongs to a group of motor system disorders marked by tremors in the extremities and face, rigidity of the limbs and trunk, slow movement, and impaired balance and coordination. As these symptoms become more pronounced, patients may have difficulty walking, talking and performing other simple tasks. Problems with voice and speech are believed to be related to the motor and sensory deficits of the disease, but the neural mechanisms behind these problems are not well understood.

Traditional methods of speech therapy, namely those focusing on articulation and rate of speech, largely have been unsuccessful in PD patients, especially in the long run.

Enter Lee Silverman—a woman with speech and voice deficits accompanying PD. In 1987, Silverman's family mused to Dr. Ramig, "If only we could hear and understand her." Inspired by Lee, the Silverman family established the Lee Silverman Center for Parkinson's Disease in Scottsdale, AZ. It was at this center that Ramig and her colleague, Carolyn Mead Bonitati M.A., began to develop the innovative treatment that now is known globally as LSVT.

"The development of LSVT was motivated by the recognition that the reduced ability to communicate is one of the most difficult aspects of PD," says Ramig. " For those with PD, voice disorders can contribute to their isolation from others and can adversely affect their social, economic, and psychological well-being."

How LSVT Works

In a manner of speaking, LSVT is to the voice what sit-ups are to the "abs": a focused workout. LSVT concentrates on a simple set of tasks designed to improve voice and respiratory functions. Speech-language pathologists instruct and constantly stimulate patients to produce a louder healthy voice by using increased effort. Patients also are continually reminded to monitor the loudness of their voice and the effort it takes to produce it. The treatment is intensive, requiring four one-hour sessions per week for four consecutive weeks.

The loud and effortful tasks are aimed at stimulating increased movement in the respiratory and laryngeal systems to improve air movement and vocal fold closure as well as vocal tract function involved in speech. The physiological changes that take place as a result of the treatment have been found to improve voice quality and loudness, articulation, and speech intelligibility. When coupled with appropriate feedback and auditory self-monitoring, LSVT can help those with PD retrain motor output during speech production and learn the relationship between increased loudness and improved speech.

According to Ramig, it is challenging for individuals with PD who normally speak softly to comprehend fully the impact of their reduced loudness and to learn to regulate this in normal conversation. Patients often feel as if the whole world needs a hearing aid and that they are shouting. However, during the course of daily treatment, they learn that if they don't feel as if they are talking too loudly they are not talking loudly enough. Patients learn that what feels "too loud" to them is a level that helps listeners hear and understand them.

Ramig adds that by targeting loudness, people with PD are tapping into well-established centrally stored areas of motor control in the brain involved in speech production. Increasing loudness to improve speech is a common and natural function of normal speech, she says, and does not require concentrating on rate of speech, pauses, or precision in articulation, all of which may be more difficult for persons with PD. The patient has one simple target with a functional impact—to "be loud"—with the benefits extending across the entire speech production system.

Research on LSVT Shows Benefits

In various clinical studies, LSVT has been shown to be an effective speech treatment for persons with PD. LSVT works well with patients who have cognitive impairments as a result of their PD. "On the surface, the treatment is redundant, simple, and intensive and thus may help compensate for the processing, speed, memory, and executive function problems seen in patients with PD and allow them to learn," says Ramig.

Other areas of improvement that have been found through LSVT are:

• More stable motor speech output;
• Improved ability to convey emotion through facial expression and voice;
• Stimulation of right-brain activity as well as of the centers of the brain known as the limbic system, a driving mechanism behind the ability to speak;
• Improved swallowing ability in a number of patients.

So far, efficacy studies on just under 100 patients have shown LSVT to be effective over the short and long term. While LSVT is being used effectively today in 30 countries, large-scale, multisite clinical trials looking at the effects of different variables such as age, stage of disease, time since diagnosis, and cognitive abilities need to be conducted to provide a more complete picture of LSVT. More comparison studies with persons receiving alternative treatments also need to be done.

Research so far has not been able to isolate the exact reason for LSVT's success: Is it due to the focus on phonation, the intensity of the treatment, or the sensory awareness training? Researchers are exploring ways to improve methods to assist with at-home use and practice of LSVT, thus potentially extending its positive long-term outcomes. Through support from NIDCD, Ramig and her colleagues are turning to technology, including the use of webcam, software programs, and a virtual therapist to help patients receive additional access to treatment that may help improve their communication abilities.

Ramig emphasizes that in speech therapy for PD patients, control rests with the patient. "Effective speech therapy carries the added benefit of improved self-confidence and better quality of life, and some measure of control over a significant symptom of PD." As more information is obtained on LSVT, researchers can find new ways to help people with PD improve their communication abilities.

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