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Big and Loud

Jun 21, 2018 06:00AM ● By Alex Strauss

By Alex Strauss

Among the many devastating effects of Parkinson’s Disease, the loss of the ability to communicate clearly and move normally are two of the most challenging for both patients and families.

As Parkinson’s progresses, nearly 90 percent of patients experience changes in their voice, including reduced volume, hoarseness, slurring, and a tendency to speak in a monotone. Although most Parkinson’s patients report having problems with communication as a result of these changes, only 3 to 4 percent ever receive speech therapy. Until recently, even those who did have therapy rarely experienced lasting results.

              Speech-Language Pathologist
            Candace Zweifel, MA, CCC-SLP

Few people are more familiar with the problem than Speech-Language Pathologist Candace Zweifel, MA, CCC-SLP, who provides speech therapy at Sanford facilities in Vermilion and Canton.

 “I was running these people through traditional speech therapy for speech and voice changes,” says Zweifel. “But three to six months later, they were showing decline. We know that Parkinson’s is degenerative but we also know that these patients were able to maintain in other area, so why not with the voice?”

Zweifel’s search for a better alternative led her to the Lee Silverman Voice Treatment Loud Program, or LSVT Loud, the first speech treatment with Level 1 evidence and established efficacy for treating voice and speech disorders in Parkinson’s.

Zweifel became LSVT Loud certified in 2014 and now helps make it possible for rural patients to get this specialized therapy without having to travel far from home. The concept is deceptively simple: During an intensive 16-session program over the course of a month, Zweifel works with patients on a single goal—speaking louder.

“It is the concentration on this one thing - being loud - that does the trick,” says Zweifel. “Parkinson’s patients often think they are speaking normally when in reality they are speaking very softly. Having them concentrate only on being loud improves not only volume but articulation, pitch range, and even swallowing.”

Just as importantly, more than 30 years of research on the LSVT Loud method shows that patients are typically able to maintain their improved communication skills for up to two years after therapy.

“We are seeing wonderful quality of life outcomes,” says Zweifel.

                 Canton Physical Therapist
                      Becky Berentschot

 In fact, the results with LSVT Loud were so dramatic that physical therapists working with mobility issues in Parkinson’s patients began to take note and the LSVT Big program was born. Canton Physical Therapist Becky Berentschot was certified in the method last fall and has been using it with her Parkinson’s patients since January.

“Basically, LSVT Big took the concept of LSVT Loud and adapted it for movement,” explains Berentschot. “Parkinson’s patients develop slower, smaller movement patterns as the disease progresses. Just like with soft speech, they may think they are walking at a normal speed when they are really walking very slowly.”

The dramatic depletion in dopamine among Parkinson’s patients robs them of their ability to execute automatic, smooth movements. Berentschot helps patients “recalibrate” their concept of normal movement by teaching them to do everything bigger.

“We walk big. We move our arms big. If you sit in the chair, you pull the chair out big and sit down big,” says Berentschot. “They think they are over-exaggerating, but they are actually moving normally.”

As with LSVT Loud, patients attend four 60-minute session a week over the course of a month and are trained to do additional daily “homework” exercise. LSVT Big can be adapted for both gross and fine motor skills. In addition to increasing mobility, it has also been shown to improve balance, increase trunk rotation, and make daily living easier for Parkinson’s patients.

“People see such wonderful results,” says Zweifel. “They don’t mind putting in the work and keeping up with it.”


  • 90 percent of patients improve vocal loudness after treatment

  • 80 percent of patients maintain treatment improvement in their voice for 12 to 24 months

  • 100 percent of patients report improved communication ability


  • Faster walking, bigger steps

  • Improve balanced

  • Increased trunk rotation

  • Improvements in activities of daily living

  • Improve UPDRS motor score

Web Extra:

Learn more about LSVT Big and Loud therapies and research