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Johns Hopkins Voice Center



LSVT PROGRAMS

LOUD logo
LSVT logo


Learn how communication and movement can be improved with LSVT programs and what loved ones can do to help.

LSVT LOGO
LSVT LOUD is an effective speech treatment for people with Parkinson's disease (PD) and other neurological conditions. Named for Mrs. Lee Silverman (Lee Silverman Voice Treatment), a woman living with PD, it was developed by Dr. Lorraine Ramig and has been scientifically studied for over 25 years with support from the National Institute for Deafness and other Communication Disorders within the National Institutes of Health (NIH) and other funding organizations. LSVT LOUD trains people with PD to use their voice at a more normal loudness level while speaking at home, work, or in the community. Key to the treatment is helping people "recalibrate" their perceptions so they know how loud or soft they sound to other people and can feel comfortable using a stronger voice at a normal loudness level.

While LSVT LOUD treatment has helped people in all stages of PD, the majority of research has been on those in moderate stages of the disease. LSVT LOUD has also helped people with atypical parkinsonisms, such as progressive supranuclear palsy (PSP), and has recently shown promise for adults with speech issues arising from stroke or multiple sclerosis and children with cerebral palsy or Down syndrome. Beginning your work with LSVT LOUD before you've noticed significant problems with voice, speech and communication will often lead to the best results, but it's never too late to start. LSVT LOUD has the potential to produce significant improvements even for people facing considerable communication difficulties.
LSVT LOGO
LSVT BIG trains people with Parkinson disease (PD) to use their body more normally. People living with PD or other neurological conditions often move differently, with gestures and actions that become smaller and slower. They may have trouble with getting around, getting dressed and with other activities of daily living. LSVT BIG effectively trains improved movements for any activity, whether “small motor” tasks like buttoning a shirt or “large motor” tasks like getting up from sofa or chair or maintaining balance while walking. The treatment improves walking, self-care and other tasks by helping people “recalibrate” how they perceive their movements with what others actually see. It also teaches them how and when to apply extra effort to produce bigger motions – more like the movements of everyone around them.

Because LSVT BIG treatment is customized to each person's specific needs and goals, it can help regardless of the stage or severity of your condition. That said, the treatment may be most effective in early or middle stages of your condition, when you can both improve function and potentially slow further symptom progression. Beginning your work with LSVT BIG before you've noticed significant problems with balance, mobility or posture will often lead to the best results, but it's never too late to start. LSVT BIG can produce significant improvements even for people facing considerable physical difficulties.


OUR TEAM

Marisa Sanders, MFA, MA, CCC-SLP, LSVT LOUD® Certified

Marisa Sanders, MFA, MA, CCC-SLP, LSVT LOUD® Certified

Speech-Language Pathologist

Marisa received her Master of Arts degree in Speech-Language Pathology from Northern Illinois University and completed her clinical fellowship at the Johns Hopkins Voice Center. Prior to her career in speech pathology, she worked as a professional actor in New York City and Chicago. She holds a Master of Fine Arts degree in Acting from The Actors Studio Drama School and a Bachelor of Arts degree in English from Clemson University. Marisa is certified in Lee Silverman Voice Treatment and has extensive training in the Alexander Technique, yoga, and dance.


Michael D. Wah, PT, OCS, LSVT BIG® Certified

Michael D. Wah, PT, OCS, LSVT BIG® Certified

Mike Wah graduated from the University of Maryland School of Medicine, Department of Physical Therapy in 1982. He has provided care in all aspects of the rehabilitation continuum including hospital inpatient, sub acute, long term rehabilitation, home health and outpatient. He was board-certified as an orthopedic specialist in 1990 and recertified in 2000. He is a Doctor of Physical Therapy candidate beginning in May of 2014. He employs evidence-based care and a wide variety of manual therapeutic techniques to meet the needs of patients with musculoskeletal conditions and soft tissue-related pain. In addition to “hands-on” care, he emphasizes patient education and active rehabilitation programs. He has many years of specialized experience helping individuals with work-related injuries and lends his expertise to GBMC’s Employee Health department.” Mike has received specialized training and has years of experience in treating individuals with vestibular disorders, dizziness and other conditions that can lead to abnormal gait and falls. Through clinical examination and specialized testing, he is able to discern the key factor(s) contributing to instability and fall risk. He is skilled in evaluation and manual treatment of Benign Paroxysmal Positional Vertigo (BPPV). He is able to meet the rehabilitation needs of those with vestibular hypofunction, neurologic movement disorders and gait deficits related to musculoskeletal impairment.


Emily Wood, DPT, ATC, LSVT BIG® Certified

Emily Wood, DPT, ATC, LSVT BIG® Certified

Emily Wood graduated from Towson University with a degree in athletic training and practiced for two years as Towson High School’s head athletic trainer. Emily followed her interest to expand her knowledge and obtained her Doctorate of Science degree in Physical Therapy from University of Maryland, Baltimore in 2012. Her background in sports injuries allows her to assist patients back to activity at all ages and stages of life. Emily enjoys working with the orthopedic and other musculoskeletal patient challenges and intends to earn advanced certification as an orthopedic manual therapist.






MAKE AN APPOINTMENT

Laryngeal Exam Prior to LSVT LOUD
Because many factors can cause changes in perceptual voice quality, an exam of the vocal folds by an ear, nose and throat doctor (ENT) is required before LSVT LOUD treatment. This allows the physician to identify any co-occurring causes or contra-indications (e.g. laryngeal masses, gastric reflux, vocal fold paralysis) that may affect therapy planning and outcomes. These conditions may need to be managed prior to the start of LSVT LOUD.

We recommend that all people with PD be referred for speech, physical and occupational therapy evaluations as soon as possible upon diagnosis, as PD affects both the speech and limb motor systems.

The evaluating therapist can establish baseline performance data, determine the need for treatment and help the person with PD choose the best treatment for his or her symptoms.

Symptoms may be subtle at first, and people often fail to notice changes or deny any concerns, but we know that by diagnosis, the neuropathology already is anything but “early.” Speech, physical and occupational therapists can “unmask” subtle and hidden deficits and educate people with PD on the best time to start therapy.

That said, it’s never too late for evaluation and treatment. People in later stages of PD and with atypical parkinsonisms can gain benefits from treatment.

LSVT Certified Clinicians can conduct trial therapy to determine treatment potential for later-stage patients. Further, treatment exercises can be adapted to accommodate for comorbidities or cognitive impairments that may be present.
There are times your referrals may be for speech, physical and occupational therapy in general – allowing the evaluating therapist and patient to determine the best course of treatment. In other cases, you may be referring specifically for LSVT treatments. If so, a few considerations are listed below.
  • The prescriptions should be for evaluation as well as treatment.
  • Separate referrals are required for LSVT LOUD (SLP) and LSVT BIG (PT and/or OT).
  • It’s helpful to explicitly prescribe the minimum treatment frequency of 4 sessions per week for 4 consecutive weeks.


WHAT YOU SHOULD KNOW

LSVT programs are evidence-based speech, physical or occupational therapies. LSVT stands for Lee Silverman Voice Treatment. Named for Mrs. Lee Silverman, a woman living with Parkinson’s disease (PD), it was developed by Dr. Lorraine Ramig and has been scientifically studied for over 25 years with support from the National Institute for Deafness and other Communication Disorders within the National Institutes of Health (NIH) and other funding organizations.

Today there are two distinct LSVT therapy programs: LSVT LOUD speech therapy improves communication in daily living; and LSVT BIG physical or occupational therapy improves mobility and movement used in everyday function.

These are not general exercise programs. Instead, they are research-based treatment protocols designed specifically to address the motor, sensory and non-motor symptoms that many people with PD face. LSVT LOUD and LSVT BIG treatments can only be given by specially trained LSVT Certified Clinicians. With their guidance, people with PD will learn to translate skills built during treatment into better everyday communication, function and movement.

Research on LSVT LOUD has documented that people with PD show improvements in loudness and intonation of their speech, as well as clarity of speech, facial expressions, and some preliminary data on swallowing. The research on LSVT BIG is newer, and not as comprehensive as for LSVT LOUD, but it is growing. Studies have shown people with PD improved walking, balance, and activities such as rolling in bed.


People often see the best results when they begin LSVT treatments before noticing significant problems, but it's never too late to start! Treatments are customized to each person's specific needs and goals, so regardless of the stage or severity of your condition, LSVT LOUD and LSVT BIG can produce significant improvements, even if a person is already facing difficulties.

That said, we’ve found that treatment is most effective for people in early or middle stages of their conditions. Keeping one’s voice and movements alive and strong when first diagnosed is much easier than later restoring speech and movement after changes have become more noticeable.

Ask Your Doctor for a Referral & Prescription

Ask your doctor about referrals to speech, physical and occupational therapies:
  • Speech therapy for LSVT LOUD
  • Physical or occupational therapy for LSVT BIG
  • The prescription should be for evaluation as well as treatment
  • It is helpful if the prescription explicitly includes the minimum treatment frequency of 4 sessions per week for 4 consecutive weeks
  • Schedule an appointment with our LSVT Certified Clinician and have your doctor provide a referral

Learn about Insurance & Reimbursement

Check with your insurance provider to learn what therapy benefits your insurance plan offers. LSVT BIG and LSVT LOUD are billed in the same way as other speech, physical and occupational therapies.

Your LSVT LOUD or LSVT BIG clinician will also be able to give you resources to help with the reimbursement process if needed.

LSVT Certification Required

You may be wondering why any licensed speech, physical or occupational therapist cannot deliver LSVT LOUD or LSVT BIG treatment without LSVT certification. Requiring therapists who want to provide LSVT treatments to first complete training and certification ensures that your LSVT treatments will be given correctly and consistent with what research has shown to be most effective.
Because PD affects both speech and movement, we strongly recommend that you receive both treatments as soon as possible after diagnosis. Both treatments can be undertaken in the same month. However, some people choose to receive one treatment first and the other at a later time.

The decision of how to approach treatment should be based on discussions with LSVT Certified Clinicians, your individual speech and movement goals, your schedule and your insurance resources, all of which may impact your plans. Certified Clinicians can help you understand your options and can offer advice and guidance.
There are a few helpful hints and considerations that may be useful to you and your family or care team in preparation for LSVT LOUD or LSVT BIG treatment. These are not requirements and may not apply to all people with PD, but we find they can be useful tips. Of course your individual LSVT Certified Clinician will provide you with the most tailored recommendations for your individual needs and situation.
  • Scheduling. LSVT is an intensive treatment that requires one hour treatment sessions, four days a week for four weeks, along with daily homework exercises. It is helpful to plan ahead with your schedule and determine the best time to start to ensure your success (e.g. no conflicts with upcoming vacations). Ultimately 16 hours is a very small investment for the benefits of improved communication or mobility. You deserve it.
  • Transportation. For some people with PD it is important to consider transportation to and from daily treatment sessions. You and your family may need to organize a schedule across the one month of treatment utilizing friends, family, and even public transportation. Planning ahead can make transportation logistics less stressful during treatment.
  • Cleared for Exercise. For some people with PD, there may be other co-occurring medical or orthopedic conditions that could impact when to start LSVT treatments. It may be recommended to get medical clearance first. It is also advisable to be stable on your current PD medications before starting LSVT LOUD or LSVT BIG.
  • Laryngeal Exam. Before starting LSVT LOUD, a visit to an Ear, Nose and Throat doctor is required to be certain there are no co-occurring causes for the changes in voice and speech. Other medical conditions, such as gastric reflux or vocal fold paralysis, can also cause hoarse, soft or breathy voice quality. These conditions may need to be managed before starting LSVT LOUD.
  • Preview LSVT Exercises.While you're waiting to start treatment, our LSVT LOUD and LSVT BIG videos can introduce you to exercises that will be used in treatment. These videos DO NOT replace therapy, but they can help you prepare in advance and familiarize yourself with what to expect once you begin treatment with your LSVT Certified Clinician.

Learn about PD, LSVT LOUD and LSVT BIG

It’s helpful to understand what people with PD experience as well as the theories and science behind LSVT treatments. Here are three easy ways to learn more:
  • View FREE Educational Live Webinars
  • View FREE Educational On Demand Webinars
  • Attend a Free Educational Seminar in Your Area
  • Recognize Non-Motor Symptoms

    It’s also helpful to understand the non-motor symptoms of PD. Parkinson’s effects on the brain can cause depression, anxiety, apathy and lost interest in things people used to enjoy.

    This can seem like sluggishness or other “moods,” but nothing could be further from the truth. That vibrant person you knew is still inside but hidden by a masked face and blunted by these common non-motor symptoms.

    The good news is that encouragement from you can help greatly! You’ll discover that after four weeks of intensive LSVT LOUD and/or LSVT BIG treatment, your loved one with PD may be more active, more social, more confident and more empowered to re-engage life!

    Remember How PD Affects Voice & Movement

    Because of how the disease affects perception, many people with PD truly don’t realize that their voices are too soft, their posture stooped or leaning to one side, or their movements uncommonly small or slow.

    Even once made aware of these issues, it might be difficult for them to make the effort to speak more loudly, sit up straighter, or use larger and faster movements. It also might be difficult for them to remember to make those adjustments.

    LSVT LOUD and LSVT BIG include intensive training in “sensory re-calibration” to A) help people recognize their differences in perception, B) learn to make the effort to correct them, and C) gain the confidence to apply that effort in daily life outside of therapy.

    Achieving those results is not always easy, but years of research and clinical practice have taught us that not only is sensory re-calibration possible, it’s critical for lasting, meaningful improvements.

    Find Out How You Can Help!

    Persons with advanced PD or other cognitive changes may need reminders to do the daily home exercises that are vital to successful treatment. They may even benefit from your coaching!

    The LSVT Clinician may provide you with some education to help you be the best coach possible. You can also practice LSVT exercises yourself or with the person you’re supporting using our Homework Helper videos!

    Please note, however, that if you’re unsure about your ability to perform any exercises safely, it’s important that you first consult the LSVT Clinician providing treatment.

    Empowering People with PD

    Sometimes therapists want their patients to work without assistance to help them gain confidence and independence using their louder voice and bigger movements in daily living.

    If this comes up, please don’t feel you’re being “dismissed” or that your desire to help isn’t appreciated! Support is always appreciated. It’s simply a matter of the therapist doing what he or she believes is needed to best help and fully empower the person with PD.

    Keep It Simple

    People with PD do best with reminder cues that are very short and to the point. For people who have received LSVT LOUD treatment, a quick, “Think LOUD” reminder is helpful from time to time.

    For LSVT BIG, the cue is “Think BIG” or just “BIG!” You can also pair “BIG” with other words, as in “BIG posture,” “BIG Steps,” and so on. The LSVT BIG therapist will know which movements you may need to cue more often in daily life.
The standard LSVT LOUD and LSVT BIG treatment programs each span four weeks of treatment sessions (four times per week) plus daily homework and carryover exercises.

Once that initial treamtent is over, you'll continue to practice at least once a day for 10–15 minutes to help maintain the gains you worked hard to achieve. It’s important to know that LSVT helps you on a continued basis in this journey of PD.

After LSVT LOUD Treatment

  • Continue your daily homework exercise routine just as you take your daily medication!
  • Use the LSVT LOUD Homework Helper video
  • LSVT Companion speech software system
  • Participate in LOUD for LIFE exercise classes
  • Schedule periodic assessments and tune up sessions with your LSVT LOUD Certified Clinician
  • Use your louder voice all day, every day at home, work, or play

After LSVT BIG Treatment

  • Continue your daily homework exercise routine just as you take your medicine every day!
  • Use the LSVT BIG Homework Helper video
  • Participate in BIG for LIFE exercise classes
  • Schedule periodic assessments and tune up sessions with your LSVT BIG Certified Clinician
  • Use your bigger movements all day, every day at home, work and play
  • Don’t stop at just doing your LSVT BIG exercises. Keep doing them daily AND find other physical activities you enjoy.
LSVT® is a trademark of LSVT Global, Inc., registered in the U.S. and other countries. Copyright 2019 LSVT Global, Inc. All rights reserved.

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