Becoming BIG and LOUD

RVNAhealth Offers Unique Therapy Programs for Patients with Parkinson’s Disease

RVNAhealth has introduced two new therapy offerings —
LSVT* LOUD (*Lee Silverman Voice Treatment) and LSVT BIG. Both are geared toward improving function in those with Parkinson’s disease.

Often referred to as “the incredible shrinking disease,” Parkinson’s is a degenerative condition characterized by a progressive loss of motor function, impacting both speech and movement. Parkinson’s affects nearly a million Americans today.

The LSVT LOUD and LSVT BIG programs are designed to improve patients’ quality of life and confidence by addressing their diminishing vocal and physical capabilities. As Parkinson’s progresses, a patient’s voice becomes quieter and movement becomes smaller, although the patient does not necessarily recognize these changes. “There is a disconnect in how a patient perceives his or her voice,” says RVNAhealth speech pathologist Cheryl Rafferty, MS CCC-SLP and LSVT LOUD therapist. “They hear it as louder than it is.” The same is true of movement.

LSVT LOUD and LSVT BIG address this disconnect through structured activities that re-train patients’ brains to amplify their vocal range and exaggerate their movements.

Both programs follow follow the same essential model and both require a strong commitment from the patient.  Therapists describe it as a “lifetime commitment,” though the program itself lasts for just four weeks.  “When patients commit to the program and see an improvement in their ability, it’s a big motivating factor,” says RVNA’s Casey Sarmiere, PT and LSVT BIG therapist. “Often, friends or family see the improvement first and comment on how much better the patient is moving or how much louder his voice sounds. It really makes the patient want to put in the time to keep up the work.”

Each program involves one hour of therapy four times a week for four consecutive weeks. During these weeks, the patient also has daily homework exercises. At the conclusion of the program, the patient is given a maintenance plan of exercises to complete every day in order to maintain their function. The ultimate goal behind both programs is for patients to make enough progress during the four weeks of therapy that they continue the work on their own.

In order for LSVT LOUD and LSVT BIG to be truly successful, early intervention is key. Ideally, patients will begin therapy before symptoms even emerge so function is not yet diminished.

“Part of our job is to educate patients so they know to ask their doctors to refer them for BIG and LOUD sooner rather than later,” adds Sarmiere.  “The sooner a patient begins therapy, the better the outcome.”

RVNAhealth currently offers both LSVT BIG and LSVT LOUD in the homecare setting. Rehab by RVNA also offers LSVT BIG in our facility at 27 Governor Street in Ridgefield, and plans to offer LSVT LOUD on site in the future as well.  Please check with your insurance provider to determine your coverage for these programs.  For more information, call 203-438-5555

The Specifics: How BIG and LOUD Really Work


Common speech problems that Parkinson’s patients experience include a soft voice, mumbled speech, monotone speech, and a hoarse voice. LOUD tackles these issues with structured activities that work the patients’ vocal range and teach them to increase volume without straining their voices.  In each session, the therapist takes the patient through a series of rigorous vocal exercises that alternate between loud and soft.

The patient brings his or her voice to a high/loud level 15 times, followed by 15 vocal “lows.” The patient also holds a vocal “ahhh” at each level, and repeats 10 specifically-designed sentences. The ultimate goal is to improve loudness, improve speech intelligibility, increase facial expression, and improve confidence.


Developed under the same principles and used in conjunction with LOUD, the LSVT BIG program addresses the issues that Parkinson’s patients experience relative to movement. As with their vocal ability, patients’ movements become smaller and more tentative as their disease progresses.  Here again, their perception of their movement is vastly different from reality. Often, a patient needs to be shown a video of their movement in order to understand how limited it has become.

As with the LOUD program, LSVT BIG aims to retrain a patient’s brain so their perception of their movement is more accurate and so they become able to move with more amplitude. In each session, the therapist takes the patient through a series of seven whole-body exercises that involve reaching up and down, and moving side to side or back and forth. Basic walking with big steps is also a component. Exercises are all exaggerated to reinforce that the patient needs to make his or her movements bigger.

LSVT BIG also incorporates training in any daily task that causes the patient difficulty. This can be something as simple as picking up a hairbrush or buttoning a shirt to more involved tasks such as doing laundry or getting in and out of a car. Therapists can also simulate complex scenarios, like shopping in a busy store, by placing obstacles in the patient’s way and working on how to navigate around them.

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