Inside Your Toolbox: Parkinson’s and LSVT-BIG
Written by Joey Masri PT, DPT
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Here comes Filbert, the 71-year-old retiree you evaluated last Friday. From the window of your clinic, you see that he’s sporting a rather fashionable bomber jacket from his high school football days. He wears grey sweatpants and his feet are decorated with brown slip-on Birkenstocks. Filbert certainly dresses to impress. As he approaches the front door, he walks slowly as his feet barely clear the floor. The cane in his right hand serves little purpose as it hovers over the ground with each step. Upon entering, he utters a good morning to the receptionist with minimal change to his facial expression. As he sits and waits to be called in for treatment, his left hand presents with the slightest tremor. You see Filbert has Parkinson’s disease – a neurodegenerative disorder that is increasing in prevalence as our population gets older. Its effects have major functional and quality of life ramifications which are often left up to therapists to address. Recently, I was fortunate enough to attend a certification course for LSVT-BIG, a treatment program designed for patients with Parkinson’s and other neurological disorders. I would like to discuss the details that surround this style of treatment and hear about your opinions and experience with such an approach.
While I wouldn’t dare bore, or excite, you with the prospect of an in-depth neuroscience lecture, it is important to cover a few points in order to understand how a pathology like Parkinson’s disease manifests itself – at least when we’re talking about the motor system. In the brain, the basal ganglia is responsible for a number of functions – including initiation, sequencing, and termination of movement. Within this structure, normal movement commands occur through careful modulation of the direct and indirect pathways to the thalamus, the main excitatory communicator to the motor cortex. The result of the direct pathway is an excitatory response leading to a desired movement, whereas the result of the indirect pathway is an inhibitory response producing less movement. Dopamine, a neurotransmitter released by the substantia nigra pars compacta (SNpc), is a key component in this process, functioning as an excitatory influence on the direct pathway and a dampening influence on the indirect pathway. Did I lose you yet? Don't worry - what's important to know is that the net result of this interaction is normally a well-tuned excitatory motor response. In Parkinson’s disease, the dopaminergic neurons at the SNpc progressively die off – leading to less dopamine available overall. Therefore, there is less excitation of the direct pathway and less inhibition of the indirect pathway occurring. The result is a common clinical manifestation of Parkinson’s – hypokinesia – or reduced amplitude of movement. It is this clinical sign that a treatment approach like LSVT-BIG is designed to address.
The above diagram compares the substania nigra of a non-Parkinson's patient with that of a Parkinson's patient. For more information on the relevant neuroscience and anatomy involved, I recommend the following supplemental reading [PDF].
What is LSVT-BIG?
LSVT stands for Lee Silverman Voice Treatment and was originally developed in the late 80’s in order to combat the speech deficits seen with Parkinson’s and other neurological conditions. Now dubbed LSVT-LOUD, the goal of the treatment is to stimulate the muscles of the larynx and improve the overall speech mechanism through a systematic order of exercises and the key verbal command of “Speak LOUD!” Over time, there has been research data to support its effectiveness in a number of areas of speech, including articulation, swallowing, and speech volume . There is also a pre/post-treatment video of LSVT-LOUD available on YouTube posted by LSVT Global.
LSVT-BIG applies the same principles of LSVT-LOUD to the motor system – specifically training for intensive, high AMPLITUDE of movement. Patients, through a set of both standardized and individualized exercises, are cued to “Move BIG!” in order to combat the hypokinetic consequences of their condition. Like in Filbert’s case above, hypokinesia causes impaired movement quality such as a progressively shortened stride length and “shuffling” gait pattern. This tendency clearly poses both a functional and safety concern that needs to be addressed. But LSVT-BIG is not just about moving bigger in an attempt to move better. There’s a little more to it than that. When cuing for this high amplitude of movement, patients frequently report feeling somewhat silly, stating that they are moving “too big” or “like a robot.” This is due to a SENSORY issue within the patient, specifically a lack of self-awareness and self-perception. Patients often do not recognize the lack of quality in their own movement. Everything feels completely normal to them, just like it would feel in a healthy individual. However, that is not what their family or clinicians observe. Therefore, the goal of LSVT-BIG is not only to normalize movement amplitude, but also to normalize the sensory/proprioceptive issues of the patient. The idea is that over time, their motions will LOOK and FEEL right. Check out this video showing the pre/post treatment results of LSVT-BIG training in a patient with Parkinson's disease.
Now, a clinician cannot just tell their patients to “Move BIG!” while performing straight leg raises for 5 sets of 10. LSVT-BIG is a standardized program with specific exercises and dosage requirements that allow for consistency of treatment and accuracy in research. This includes:
- 1-hour sessions
- 4 consecutive sessions/week for 4 weeks = 16 total sessions
- Progressive increases in difficulty to force adaptation
- High intensity effort meant to challenge the system (>8/10 at all times)
A treatment session requires a patient to perform a specific set of dynamic movements that are done in both sitting and standing under the direction of a certified physical or occupational therapist. In addition, individualized exercises are created for each patient in order to address certain functional/ADL goals. Specifics on the details of this have been purposely omitted from this post. A training course is required in order to learn the proper form and technique of the exercises.
While LSVT-BIG’s primary goal is to improve on movement amplitude. There are a number of proposed secondary benefits:
- Improved balance
- Improved strength and range of motion
- Improved postural alignment
- Improved aerobic conditioning
- Improved emotional state
Research – Does LSVT-BIG work?
The research, at this time, would seem to support the use of LSVT-BIG programming in a patient’s proposed plan of care. In 2010, Ebersbach et al. looked at 60 patients with mild to moderate Parkinson’s disease and assigned them all to either one-on-one LSVT-BIG training, group Nordic walking training, or a non-supervised home exercise program. The United Parkinson’s Disease Rating Scale motor score (UPDRS III), Timed Up and Go (TUG), and 10-meter walk test (10MWT) were all utilized as outcome measures. The results were improvements in the UPDRS III for the LSVT-BIG groups, with worse scores in the Nordic walking and Home groups. The LSVT-BIG group additionally boasted relatively superior improvements in the TUG and 10MWT. The same group of researchers later utilized this data to find that subjects in the LSVT-BIG group also exhibited improvements in overall reaction time.
In a case series, Janssens et al. looked at three patients with mild-moderate Parkinson’s and applied the LSVT-BIG training program to them. They found improvements in gait and balance as demonstrated by increased scores on the Functional Reach Test and Functional Gait Assessment, and decreases in scores on the TUG, Freezing of Gait Questionnaire, and UPDRS III. The subjects were also quicker in performing tasks related to bed mobility, per the Lindop Parkinson's Disease Mobility Assessment.
In addition to hypokinesia, a common clinical sign in patients with Parkinson’s disease is slowness of movement (bradykinesia). A study by Farley et al. found that with high-amplitude exercise intervention, significant improvements in SPEED of reaching and gait were obtained. Less severe patients, per staging by the Hoehn and Yahr scale, had the most pronounced improvement. This result suggested a carryover effect of amplitude to speed - making it possible to indirectly train for this component.
In order to administer the LSVT-BIG program and market yourself as such, you must become certified in it. There are in-person and online options available for certification. The in-person certification workshop is a two-day program that includes a lecture and lab portion, with a written examination at its conclusion. The online option offers 40 training modules based on the same content as the in-person workshop that allows you to repeat content as many times as you’d like.
Readers interested in more information on the LSVT-BIG certification and available in-person workshop dates are encouraged to visit the website of LSVT Global.
I was first introduced to the concepts surrounding LSVT-BIG during my first clinical internship. While what we did cannot be called LSVT-BIG (remember that it is a STANDARDIZED protocol administered by a LSVT-BIG Certified Clinician), we did utilize the idea of high amplitude training with dynamic exercises for a few patients presenting with impaired balance. The patients absolutely loved the experience, as it offered an attractive alternative to their typical exercise regimen (anything sounds better than standing in single-limb stance with eyes closed for 30 seconds at a time). Additionally, patients reported that therapy was a lot more fun for them and that they left their session feeling a great sense of self-worth and well-being. During re-evaluation, these patients improved their scores on the mCTSIB and Dynamic Gait Index (measures of static and dynamic balance/gait assessment, respectively). Based on this experience, I intend to continue utilizing the idea of high amplitude exercise training for patients that I feel will benefit most from it.
I would love to hear your thoughts on this treatment approach and what you have found to be effective in treating patients that present similarly. Please feel free to contact us or leave a comment below.
The LSVT-BIG and LSVT-LOUD program, its details, and the LSVT Global logo is copyrighted to LSVT Global, Inc. For more information, readers are strongly encouraged to visit their website at LSVTGlobal.com. EducatedPT has no affiliation with this organization.
- Baumgartner CA, Sapir S, Ramig TO. Voice quality changes following phonatory-respiratory effort treatment (LSVT) versus respiratory effort treatment for individuals with Parkinson disease. J Voice. 2001;15(1):105-14.
- Ebersbach G, Ebersbach A, Edler D, et al. Comparing exercise in Parkinson's disease--the Berlin LSVT®BIG study. Mov Disord. 2010;25(12):1902-8.
- Ebersbach G, Ebersbach A, Gandor F, Wegner B, Wissel J, Kupsch A. Impact of physical exercise on reaction time in patients with Parkinson's disease-data from the Berlin BIG Study. Arch Phys Med Rehabil. 2014;95(5):996-9.
- Janssens J, Malfroid K, Nyffeler T, Bohlhalter S, Vanbellingen T. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with Parkinson disease: a case series. Phys Ther. 2014;94(7):1014-23.
- Sapir S, Spielman JL, Ramig LO, Story BH, Fox C. Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson disease: acoustic and perceptual findings. J Speech Lang Hear Res. 2007;50(4):899-912.
- Sapir S, Ramig LO, Hoyt P, Countryman S, O'brien C, Hoehn M. Speech loudness and quality 12 months after intensive voice treatment (LSVT) for Parkinson's disease: a comparison with an alternative speech treatment. Folia Phoniatr Logop. 2002;54(6):296-303.