LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease

Abstract

Recent advances in neuroscience have suggested that exercise-based behavioral treatments may improve function and possibly slow progression of motor symptoms in individuals with Parkinson disease (PD). The LSVT (Lee Silverman Voice Treatment) Programs for individuals with PD have been developed and researched over the past 20 years beginning with a focus on the speech motor system (LSVT LOUD) and more recently have been extended to address limb motor systems (LSVT BIG). The unique aspects of the LSVT Programs include the combination of (a) an exclusive target on increasing amplitude (loudness in the speech motor system; bigger movements in the limb motor system), (b) a focus on sensory recalibration to help patients recognize that movements with increased amplitude are within normal limits, even if they feel "too loud" or "too big," and (c) training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes. In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning. The purpose of this paper is to provide an integrative discussion of the LSVT Programs including the rationale for their fundamentals, a summary of efficacy data, and a discussion of limitations and future directions for research.

Figure 1

We hypothesize that pretreatment (a), individuals with PD have reduced amplitude of motor output, which results in soft voice and small movements. Due to problems in sensory self-perception they are not aware of the soft voice and small movements, or they do not recognize the extent of their soft voice and smaller movements. As a result, no error correction is made and individuals continue to program or self-cue reduced amplitude of motor output. They are “stuck” in a cycle of being soft and small. The focus in treatment (b) is on increasing the amplitude of motor output by having individuals with PD produce a louder voice and larger movements. Individuals are then taught that what feels/sounds/looks “too loud” or “too big” is within normal limits and has a positive impact on daily functional living. Therefore at the end of treatment, individuals habitually self-cue increased amplitude of motor output and have attention to action. Now they are in a cycle of a louder voice and bigger movements.