The Origin of the LSVT LOUD® “AHHH” and Why it is NOT the Goal of Treatment

Have you ever wondered why LSVT LOUD therapy seems to involve so much “AHHH”-ing? If you’ve participated in or observed this therapy, you’ve likely witnessed the bountiful number of sustained “AHHHs” that are a cornerstone of each session. But why all the focus on this simple sound? And more importantly, is exercising the voice with “AHHH” really the end goal of this therapeutic approach?

(SPOILER ALERT: IT’S NOT!)

From “AHHH” to Conversation: The Real Goal

Here’s where we need to be crystal clear: The “AHHH” is NOT the goal of LSVT LOUD therapy. No one expects people with Parkinson’s to walk around saying “AHHH” at increased volume in their daily lives!

Instead, the “AHHH” exercise serves as a stepping stone upon which conversational speech is rebuilt.

LSVT LOUD follows a carefully structured hierarchy, building the vocal loudness established in the “AHHH” exercise into speech progressing in duration and complexity of speaking from:

1. Words and phrases
2. Sentences
3. Paragraph reading
4. Conversational speech

The ultimate goal? Transferring that improved vocal loudness from exercises like the “AHHH” into everyday conversational speech to enhance communicative effectiveness and quality of life. Research has consistently shown that training vocal loudness through this approach results in widespread improvements, including:

• Increased vocal loudness and improved voice quality

• Better articulation and speech intelligibility

• Improved facial expression

• Enhanced neural function during speech

• Greater communicative confidence

So, why do we do the “AHHH” anyway?

The Science Behind the “AHHH”

Let’s take a dive into why this simple vowel plays such a critical role in LSVT LOUD therapy.

LSVT LOUD was developed over 30 years ago as a specialized speech treatment for people with Parkinson’s by Dr. Lorraine Ramig. Up to 89% of people with Parkinson’s develop speech disorders characterized by reduced vocal loudness, a monotone voice, increased breathiness, hoarse voice quality, and reduces speech clarity. These communication challenges significantly impact quality of life, often leading to social isolation and frustration.

The “AHHH” exercise isn’t  random – it’s strategically chosen as a core exercise in the LSVT LOUD protocol for several important reasons:

1. It Targets a Key Problem: Breathing-Voicing Coordination

In Parkinson’s, reduced amplitude of movement and slowness of movement (hypokinesia and bradykinesia) are core motor symptoms.  These motor changes can negatively impact breathing and vocalizing (soft, breathy voice) and clarity of speech (slower and smaller movements of mouth, tongue and jaw during speech). The “AHHH” directly addresses these challenges:

• The “AHHH” Strengthens Breath Control. Your breathing system provides the power (air pressure) for voice and speech. When you sustain an “AHHH”, your vocal folds (also called vocal cords) provide resistance to the airflow from your lungs. This resistance forces your breathing muscles to work more efficiently to maintain steady pressure supporting your voice. Over time, this strengthens the coordination between your breathing muscles and your voice.

• The “AHHH” Improves Vocal Loudness. Your vocal folds create the sound source (vibration) for voice and speech. Saying “AHHH” in a loud voice helps your vocal folds close tightly. People with Parkinson’s often can’t close their vocal folds all the way, which makes their voice soft. Practicing being loud helps the vocal folds close better, making the voice stronger and easier to hear.

• The “AHHH” Enhances Coordination of Voice Systems for Speech. Your mouth, tongue and jaw shape the voice into recognizable speech. The “AHHH” improves the relationship between breathing and voicing. This increased effort from the louder voice spreads to improved movements in the mouth, tongue, and jaw producing clearer speech.

2. It Builds Vocal Endurance

Those long “AHHH”s aren’t just for fun (although they can be!). They serve as a form of “vocal weightlifting” that builds endurance. Just as you wouldn’t start a strength training program by attempting to bench press your maximum weight, LSVT LOUD begins with this fundamental exercise to build the speech production “muscles” before moving to more complex tasks.

Making “AHHH” Fun: Creativity and Challenge in LSVT LOUD

Initially, saying long, LOUD “AHHHs” might feel a little silly. But ask any LSVT LOUD participant or clinician, and you’ll quickly learn that these vocal exercises are not only important, they can actually be a lot of fun!

Here’s why:

• Simple, Yet Satisfying: The “AHHH” is a straightforward exercise, but it’s rewarding to hear your own voice grow stronger and steadier over time. Each session brings a sense of accomplishment as you sustain your voice longer, louder, and with better quality.
• Endless Ways to Level Up: Just like any exercise in strength training, the “AHHH” can be made more challenging as you progress.

Your LSVT LOUD clinician can:

• Increase the length of each “AHHH,” building vocal endurance and control.
• Add dual tasks that are personal and meaningful, like typing on a keyboard, walking, solving math problems in your head, all while sustaining good quality loudness during the “AHHH”.
• If clients are also receiving LSVT BIG physical and occupational therapy, we might even combine the long “AHHH” with some of the LSVT BIG exercises like the Floor to Ceiling sustained exercise. 

• The Barbell Curl Analogy: Think of the “AHHH” like a barbell curl for your voice. At first, you might start with a “light weight” like a shorter, gentler “AHHH.” As your vocal “muscles” get stronger, you can “add weight” by making the “AHHH” longer, louder (within healthy limits), or more complex with dual tasks. Just as a personal trainer might add reps or resistance to keep your workout effective, your LSVT LOUD clinician will keep your “AHHH” exercises challenging throughout the 16 sessions of treatment.

Raising AHHHwareness: More Than Just Noise

Our recent “Raising AHHHwareness“ campaign leverages this iconic exercise to spread the word about the effectiveness of LSVT LOUD therapy for people with Parkinson’s and adults and children with other neurological conditions. By encouraging people to share their own “AHHH” moments, we’re helping to destigmatize speech therapy and celebrate the power of finding your voice again.

So, the next time you hear someone practicing their “AHHH” as part of LSVT LOUD therapy, remember that you’re witnessing just one step in a comprehensive, scientifically-validated approach to improving communication. 

The “AHHH” may be where LSVT LOUD begins, but clear, confident conversation is where it ends.

References:

1. Fox, C., Ebersbach, G., Ramig, L., & Sapir, S. (2012). LSVT LOUD and LSVT BIG: Behavioral treatment programs for speech and body movement in Parkinson disease. Parkinson’s Disease, 2012, 391946.

2. Ramig, L., Halpern, A., Spielman, J., Fox, C., & Freeman, K. (2018). Speech treatment in Parkinson’s disease: Randomized controlled trial (RCT). Movement Disorders, 33(11), 1777-1791.

3. Smith, M. E., Ramig, L. O., Dromey, C., Perez, K. S., & Samandari, R. (1995). Intensive voice treatment in Parkinson disease: Laryngostroboscopic findings. Journal of Voice, 9(4), 453-459.

4. Fox, C. M., Ramig, L. O., Ciucci, M. R., Sapir, S., McFarland, D. H., & Farley, B. G. (2006). The science and practice of LSVT/LOUD: Neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders. Seminars in Speech and Language, 27(4), 283-299.

5. Ramig, L. O., Countryman, S., Thompson, L. L., & Horii, Y. (1995). Comparison of two forms of intensive speech treatment for Parkinson disease. Journal of Speech and Hearing Research, 38(6), 1232-1251.