1. The Science and Practice of LSVT BIG
Mohabbat Ali
Sr. Physiotherapist & coordinator SRC
Fox, C. Presentation, August, 2010

2. Describe development and key aspects of limb motor treatment LSVT BIG
Objectives
Explain advances in neuroscience and impact on the field of rehabilitation
Briefly discuss development and data on an efficacious speech treatment LSVT LOUD
Describe development and key aspects of limb motor treatment LSVT BIG
Introduce the LSVT HYBRID approach (simultaneous delivery of BIG and LOUD)
Fox, C. Presentation, August, 2010 2

3. It is an exciting time to be in rehabilitation today!
Basic science evidence for the value of exercise in PD (classically drugs, surgery, today…)
Identified key principles of exercise that drive activity-dependent neural plasticity
Demonstrated that exercise can improve brain functioning (neural plasticity) and may slow disease progression
Exercise is Medicine!
Kliem & Jones, 2008; Ludlow et al, 2008
Fox, C. Presentation, August, 2010 3

4. Legitimate Therapeutic Options
To provide symptomatic relief; improve function
Neurosurgical
(DBS-STN)
Pharmacological
(L-dopa)
Voice and Body
Exercise
Zigmond et al, 2009
Fox, C. Presentation, August, 2010 4

5. “If only we can hear and understand her”
Family of Mrs. Lee Silverman 1987
Fox, C. Presentation, August, 2010 5

6. 5 Stages of Grief Denial - “There must be some mistake!”
Anger – “I sure got shafted this time.”
Bargaining – “There must be a cure.”
Depression – “This is hopeless.”
Acceptance – “ I can deal with this.”
These stages must be worked through before any meaningful process can begin.
Source: On Death and Dying. Elizabeth Kubler-Ross

7. Copyright LSVT Global, Inc. 2011
20+ year journey from invention to intervention Over 8 million dollars in NIH funding
: Initial invention; Pilot data (Scottsdale)
: Office of Education OE-NIDRR
: OE-NIDRR
: NIH funded RCT Efficacy
: NIH funded EMG, Kinematics
: NIH funded RCT Spread of effects
: NIH funded RCT, imaging
: Coleman Institute (PDA; LSVTC)
: NIH and M J FOX Foundation PDA (R21)
: Coleman Institute (VT; LSVTVT)
: NIH LSVTVT (R21)
2004 : Coleman Institute (LSVT Down Syndrome)
: LSVT –Dissemination
2006: Technology-enhanced Clinician Training (SBIR)
2010: Technology-enhanced LSVT LOUD delivery (SBIR)
Phase I, II
Phase III
Phase IV, V
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 7

8. bradykinesia/hypokinesia kinesthetic awareness
LSVT Programs
Administered in an intensive manner to
to challenge the impaired system.
Techniques specific to PD-specific deficits!
bradykinesia/hypokinesia
and
kinesthetic awareness
(sensory deficit)
Fox, C. Presentation, August, 2010 8

9. TARGET of LSVT LOUD LOUD SOFT HEALTHY LOUDNESS
Loud is more than a laryngeal event – spread of effects
LOUD
SOFT
HEALTHY LOUDNESS
Fox, C. Presentation, August, 2010 9

10. CALIBRATION
Learning
sensory
problem,
internal cueing 10

11. LSVT LOUD
LSVT BIG
(Farley & Koshland, 2005; Farley, Fox, et al., 2008;
Farley & Koshland, in revision)
Fox, C. Presentation, August, 2010 11

12. What are the fundamentals of LSVT BIG?
Standardized, research-based, specific protocol
TARGET: Bigness (amplitude)
MODE: Intensive and High Effort
CALIBRATION: Generalization
Sensory
Internal cueing
Neuropsychological changes
Fox, C. Presentation, August, 2010 12

13. TARGET BIG (Large amplitude whole body movement)
Single Target - Triggers Activation across motor systems
SMALL
BIG
NORMAL “BIGNESS“
Fox, C. Presentation, August, 2010 13

14. MODE Delivery Time of Practice Physical Occupational Therapist
1:1 intervention
Time of Practice
4 consecutive days per week for 4 weeks
16 sessions in one month
60 minute sessions
Daily carryover assignments (30 days/entire month)
Daily homework (30 days/entire month)
Fox, C. Presentation, August, 2010 14

15. “I had no idea how small my world had become”
CALIBRATION
MISMATCH between self-perception of output and how others perceive it
“I had no idea how small my world had become”
“I can’t move like this, people will think I am crazy!!”
Fox, C. Presentation, August, 2010 15

16. normal movement effort and
CALIBRATION
Learning
Retrain sensory
calibration and learn
new internal cues for
normal movement effort and
bigness
Copyright© LSVT Global, Inc. 2011 16

17. Impaired self-perception Deficits in Small movements internal cues
reduced
amplitude of output
Copyright© LSVT Global, Inc. 2011 17

18. (consistent with principles of neural plasticity)
Goal of LSVT BIG
Mode
Intensive, High effort
(consistent with principles of neural plasticity)
Target
Calibration
Increase Bigness
increase
amplitude of output
Self-perception,
Internal cues,
Simple, Redundant
Fox, C. Presentation, August, 2010 18

19. Treatment Session Daily Exercises Functional Component Tasks
Floor to Ceiling
Side to Side
Forward step
Sideways step
Backward step
Forward Rock and Reach
Sideways Rock and Reach
Functional Component Tasks
5 EVERYDAY TASKS– 5 reps each For Example:
-Sit-to-Stand
-Pulling keys out of pocket
-Opening refrigerator door
Walking BIG distance/time may vary
Hierarchy Tasks
Patient identified tasks:
Getting out of bed
Playing golf
In and out of a car
Build complexity across 4 weeks of treatment towards long term goals

20. Daily Whole-body Maximal Amplitude Exercises
Daily Whole-body Maximal Amplitude Exercises Multidirectional Sustained Movements
Floor to Ceiling
Side to Side
Fox, C. Presentation, August, 2010 20

21. Daily Whole-body Maximal Amplitude Exercises
Daily Whole-body Maximal Amplitude Exercises Multidirectional Repetitive Movements
Sideways
Backwards
Forwards
Fox, C. Presentation, August, 2010 21

22. Functional Component TASKS Functional Components – Patient DRIVEN!
Rolling
Floor to Stand
Getting in or out of bed
Sit to stand
Sit & reach
Stand & reach
Walk & reach
Walk & turn
Stand & turn
Sit to stand BIG
Fox, C. Presentation, August, 2010 22

23. Daily Hierarchical Tasks “Real-World” BIG Tasks – Patient DRIVEN
Daily Hierarchical Tasks “Real-World” BIG Tasks – Patient DRIVEN! Examples:
Bed to Bathroom In/Out of Car Walk and Talk Tennis Chores Golf Hiking Gardening
Fox, C. Presentation, August, 2010 23

24. Patient case: Bernie
71 year-old, diagnosed with Parkinson’s disease in 1994
Reason for referral: slowness and difficulty walking, history of falls, freezing
Optimized on PD medications
Fox, C. Presentation, August, 2010 24

25. Objective Outcomes: PRE POST Falls 1-2/month 0/month
Assistive device Cane None
Confidence % %
Gait Velocity m/s m/s
% of age matched norm % 100%
Endurance ft ft
Fox, C. Presentation, August, 2010 25

26. Bernie’s Goals To improve his walking To go to the movies
To play with his grandchildren
To go out to dinner with friends and family
All accomplished to his satisfaction!
Fox, C. Presentation, August, 2010 26

27. Traditional Outpatient Physical Therapy
LSVT BIG
vs.
Traditional Outpatient Physical Therapy
Randomized Comparative Pilot Study
Matched Frequency/Duration
4X/week for 4 weeks; 1-hour individual sessions
N=42
Hoehn & Yahr 1-3
Intention to treat analysis
Farley & Koshland, in preparation (Unpublished data)
Fox, C. Presentation, August, 2010 27

28. Improvements occurred in both groups and lasted 3 months.
Walking Improvements
Faster
Bigger
BIG
TRAD
Better
1-month
3-months
1-month
3-months
Improvements occurred in both groups and lasted 3 months.
Farley & Koshland, in preparation (Unpublished data)
Fox, C. Presentation, August, 2010 28

29. Copyright LSVT Global, Inc. 2011
Trunk Rotation
TRAD
BIG
Better
1-month
3-months
Only improved for LSVT BIG
Farley & Koshland, in preparation (Unpublished data)
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 29

30. Conclusions: Activity Matters LSVT BIG may be especially important for
trunk rotation and balance - everyday movements
Fox, C. Presentation, August, 2010 30

31. Principles of LSVT applied simultaneously to the speech and limb motor systems.
LSVT HYBRID = LOUD + BIG
Combined or “Hybrid” approach for PD
May promote greater plasticity through greater intensity, complexity, saliency
Enhance practical, logistical, financial costs of PD rehabilitation
Fox, C. Presentation, August, 2010 31

32. LSVT HYBRID retrains “normal use”
“In my normal everyday life,
I just exaggerate my movements.
I keep things Big when
I reach for things,
or when I bend or when I walk;
and when I talk –
I keep my voice strong.”
Fox, C. Presentation, August, 2010 32

33. LSVT ® BIG Treatment Concepts:
1. AMPLITUDE, AMPLITUDE, AMPLITUDE
2. Sensory re-calibration
3. Intensive standardized exercise program 4. Empowering (positive reinforcement )

34. PWR! Hands

35. PWR! Reach

36. PWR!
Reach

37. PWR!
Reach

38. PWR!
Rock

39. PWR! Rock

40. PWR!
Twist

41. PWR! Step

42. PWR!
Turn

43. overview of one session
Maximal Daily Exercises Sustained Movements
Floor to ceiling
2. Side to side Repetitive Movements 1. Step and reach forward 2. Step and reach sideways
3. Step and reach backwards
4. Rock and reach forward-backwards
5. Rock and reach side to side Functional Movements ~ 5 exercises that are patient driven Ex: Rolling, STS, Walking with turns, picking up objects, reaching 2. Hierarchy Tasks Recreate real world activities that are difficult Variable and progressive Ex: Restaurants, movie theaters, Chores, leisure activities etc 3. Carryover assignments (homework)

44. Maximal Daily exercise demonstration: 
Maximal Daily exercise demonstration Refer to handout
Maximal Daily Exercises, minimum of 10 reps each Sustained Movements, repeated 10 times and held for 10s 1. Floor to ceiling 2. Side to side Repetitive Movements 1. Step and reach forward, 10 each leg 2. Step and reach sideways, 10 each leg
3. Step and reach backwards, 10 each leg
4. Rock and reach forward-backwards, 2sets of 20
5. Rock and reach side to side, 2 sets of 20 Functional Movements ~3-5 exercises that are patient driven, repeat 10x Ex: Rolling, supine to sit, STS, walk and turn, Sit and reach, stand and reach, walk and pick up object

45. Maximum Daily Exercise Tips:
Daily exercises don’t change over 4weeks Increase effort from week to week Increase reps,
duration, decrease rest,
No UE support,
remove or decrease vision,
add resistance,
add dual task Eliminate fear of falling Don’t sacrifice BIGNESS for speed,
movements are deliberate Count LOUD Stomp “Shape” alignment with minimal cognitive load Minimal explanations
“Big arms”, “Big hands”, “Big posture” Replaces:
“Pull your shoulders back, keep your chest up”, “Extend your wrists”, “straighten your knees”
Model movements
“Do what I do”

46. Summary
Advances in neuroscience have provided neurobiological and behavioral evidence supporting the positive impact of exercise-based protocols in people with PD
There is a rapidly growing literature in physical therapy/exercise protocols in humans with PD
LSVT Programs have been developed and studied over the past 20 years
LSVT BIG is one type of physical therapy program that has potential to offer improvements in movement and quality of life for people with PD
Copyright LSVT Global, Inc. 2011
Fox, C. Presentation, August, 2010 46

47. “It is possible to take charge of your life, even with Parkinson’s.
It is possible for your will
to override your brain.
It is possible to have
Power Over Parkinson’s” 47

48. Thank you for your attention!
Questions & Comments