March 15, 2023
What Is Parkinson Disease?
Parkinson Disease is defined by the National Institute of Health as, “a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. They may also have mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue.” Anyone can develop Parkinson Disease with most patients (over 90%) developing the disease after the age of 60. Parkinson Disease occurs when nerve cells of the basal ganglia, the part of the brain that controls coordination of movement, die and cannot produce the chemical dopamine. The lack of dopamine then causes the motor symptoms we most often associate with Parkinson Disease including tremors, slower and smaller movements, decreased balance, decreased facial expression. Recently it has also been discovered brain cells producing the chemical norepinephrine are also damaged causing symptoms such as low or irregular blood pressure, low heart rate, fatigue, and slower digestion and constipation.
How is Parkinson Disease Treated?
Parkinson Disease is often first diagnosed by your primary care physician or if you are working closely with a physical or occupational therapist. Your treatment is then most likely overseen by a neurologist and therapy team. Most patients are prescribed medications to help the body produce more dopamine. The most common medication is carbidopa levodopa with the levodopa stimulating dopamine production and the carbidopa decreasing the side effects including nausea, vomiting, and restlessness. Other patients are prescribed medications to improve their blood pressure or heart rate, medications to decrease the body’s ability to break down dopamine, and medications to decrease muscle tightness/ tone. One of the most effective treatments for Parkinson Disease has been a specific physical therapy treatment protocol called LSVT Big.
What is LSVT Big (and who is Lee Silverman?)
LSVT big is, “An intensive amplitude-based exercise program for the limb motor system with re-education of the sensorimotor system (LSVT Global definition).” In normal language LSVT Big is a physical/ occupational therapy program focused on increasing the amplitude of all motor systems. LSVT Big uses a Movement-As-Medicine approach teaching patients to “recalibrate” how they perceive their movements and teaching them how and when to apply extra effort to produce bigger motions. The concepts of LSVT Big were first developed by Dr. Lorraine Ramig in 1987. Dr. Ramig was working with Lee Silverman, a patient with Parkinson Disease. Ms. Silverman’s family was having difficulty understanding her as her ability to speak loudly and clearly was severely affected by the small movements her Parkinson Disease caused. She and her family had the goal of being able to communicate more clearly together and the Lee Silverman Voice Treatment program was born. This was initially a speech therapy program designed to teach the patient to use more force to produce their voice and use large movements of their mouth and tongue muscles to produce loud and clear speech. In 2002 these same concepts were then developed into a physical therapy program focusing on using increased effort/ force and large movements to produce smoother and safer physical movement.
LSVT Big is different than traditional physical therapy as it only focuses on one treatment goal increasing the amplitude of all movements. Our goal is to help the patient make everything BIG to counter act the smaller and uncoordinated movements caused by Parkinson Disease. This method guides the patient to relearn new internal cues for initiation and maintenance of movements. When a patient has completed LSVT Big they have learned to automatically use bigger movements in their everyday activities creating a long-term carryover of increased amplitude movement. LSVT Big helps patients walk faster and steadier, decrease risk of falls, decrease time and effort required to complete dressing and bathing tasks, and decrease and/or eliminate tremors. Both the patient and the therapy have to work hard for these results. The LSVT Big protocol must be delivered over 4 weekly hour-long individual sessions over 4 weeks with 16 treatment sessions, daily homework practice, and daily carryover activities. LSVT Big is supported by most major insurance carriers including Medicare and Advantage plans, and can only be performed by a physical or occupational therapist trained and certified by LSVT Global.
Is it supported by research?
The LSVT protocol has been supported by scientific research since 1989. A 2015 research study demonstrated intensive physical therapy rehabilitation in the early state of the disease can slow disease progression and lead to better motor performance. The same study also found sedentary lifestyles worsen balance and walking in people with Parkinson Disease and can accelerate the progression of the disease (Frazzitta et al, 2015). In 2013 focusing on treadmill exercise found that physical exercise causes an increase in the brain receptors to dopamine causing improved motor and postural control. This research supports the theory of neuroplasticity meaning the brain and neurological system is able to fix itself and adapt after injury or insult. The study found the larger amplitude the movement (walking vs seated exercise) the more dopamine receptors were created (Fischer et al, 2013). Some of the most exciting research results were found in 2010 when use of the LSVT Loud protocol (the original speech therapy program LSVT Big is based on) caused visible changes on a functional MRI. The researchers were able to see increased activity in the areas of the brain where motor and coordination activities take place when comparing MRIs completed before and after the LSVT treatment (Narayana et al, 2010). Parkinson Disease medication has never been shown to make the same changes on an MRI study.
How does it work?
LSVT Big therapy has a singular focus on increasing amplitude of all movements with use of intensive and high effort and teaching sensory calibration. Amplitude is defined in this case as the largest range of motion that can be performed at with the highest effort with the best form every time. When a patient has Parkinson Disease their brain is lying and tells the patient their small and weak movements are “normal.” When a patient has Parkinson Disease and they walk with small shuffle steps their brain is telling them these are “normal” steps. In LSVT big we teach the patient how to make the movement as big as possible. This elevates their small movements to normal movements. Image Source: LSVTGlobal.com
Amplitude training teaches the patient to feel and use big movements; a frequent question I ask patients after a movement is, “Did that feel big or did that feel small?” This also simplifies the training as the pt only needs to “THINK BIG” with every movement. When the patient focuses on making large movements balance, speed, and precision naturally follow.
Intensity is a key to success with the LSVT Big protocol as well. As defined in the Fischer et al, 2013 study intensity is the key to new motor learning and neuroplasticity (the brain healing itself). Intensive effort is required by the patient to override the smaller and slower movements associate with Parkinson Disease. The patient will work hard during the 4x/week LSVT Big treatment sessions but here is the good news; your therapist will work just as hard. Your therapist first has the job of picking activities and movements that are important to you. The LSVT Big trained therapist selects specific movements to achieve each patient’s individualized motor goals. Examples of goals worked on with patients include getting in and out of a restaurant booth, drinking coffee without spilling, and getting out of a nursey school sized chair on Grandparent’s day. Your therapist also completes all exercises and activities with you as well. It is your therapist’s job to model the intensity and amplitude of all movements while you are doing them to help your body match the energy and bigness needed.
The final fundamental of LSVT Big is calibration. Calibration happens when the patient knows, understands, and accepts the effort needed to consistently produce bigger and more normal movements. Patients will understand when they port forth maximal effort and intensity, they move their best. The goal is for patients to “automatically” use bigger movements all the time and in all aspects of their lives. Patients will often say, “I did not realize how small my movements had become,” and, “When I try hard and focus more I can get things done faster.”
What are you waiting for?
If you or someone you love has Parkinson Disease the best thing they can do is start an intensive physical therapy program. Obviously, at Portland PT we would love you to start one with us. Call our offices and we can get you set up with Laura (me!) our LSVT Big certified therapist. Our amazing administrative staff can assist you in determining if your insurance requires a referral from a physician or if you can schedule an appointment without a referral. Whatever choices you make remember with Parkinson Disease, “Movement is medicine,” and we would love to help you on your journey however we can.
Resources:
NIH Website: https://www.nia.nih.gov/health/parkinsons-disease#:~:text=Parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. Accessed 14 March, 2023
LSVT Global Website: https://www.lsvtglobal.com/LSVTBig. Accessed 14 March, 2023
Frazzitta G, Maestri R, Bertotti G, Riboldazzi G, Boveri N, Perini M, Uccellini D, Turla M, Comi C, Pezzoli G, Ghilardi MF. Intensive rehabilitation treatment in early Parkinson's disease: a randomized pilot study with a 2-year follow-up. Neurorehabiltation Neural Repair. 2015 Feb;29(2):123-31. doi: 10.1177/1545968314542981. Epub 2014 Jul 18. PMID: 25038064.
Fisher BE, Li Q, Nacca A, Salem GJ, Song J, Yip J, Hui JS, Jakowec MW, Petzinger GM. Treadmill exercise elevates striatal dopamine D2 receptor binding potential in patients with early Parkinson's disease. Neuroreport. 2013 Jul 10;24(10):509-14. doi: 10.1097/WNR.0b013e328361dc13. PMID: 23636255.
Narayana S, Fox PT, Zhang W, Franklin C, Robin DA, Vogel D, Ramig LO. Neural correlates of efficacy of voice therapy in Parkinson's disease identified by performance-correlation analysis. Hum Brain Mapp. 2010 Feb;31(2):222-36. doi: 10.1002/hbm.20859. PMID: 19639554; PMCID: PMC2811230.
Author: Laura Sugrue, PT, MSPT, OCS