Examining The Efficacy Of LSVT BIG Interventions to Target Gait And Balance Deficits In A Patient With Parkinson’s Disease

Sarah Coulson, SPT

Shannon Gill, SPT

Bridget Gras, SPT

Megan McDermott, SPT

Shane McKeon, SPT

Alexis Pagonis, SPT

Overview

• Purpose
• Patient History
• Parkinson’s Disease Background
• LSVT-BIG Background
• Past Medical History and Review of Systems
• Timeline
• Clinical Impression 1
• Tests and Measures
• Clinical Impression 2
• ICF Model
• Patient’s Goals
• Plan of Care
• Interventions
• Outcomes
• Discussion
• Conclusion

2

Purpose

The purpose of this case report is to examine the efficacy of the implementation of the LSVT-BIG program to a patient with Parkinson’s Disease.

3

Mr. V

• 62 y/o male
• Patient began experiencing “shakes” 2 years ago and sought out medical attention from his doctor
• Currently diagnosed with early-middle stage Parkinson’s Disease
• Reported improvement in symptoms after addition of medication; however, recently started noticing more unsteadiness on his feet, fear of falling, and a decline in his functional abilities

4

Parkinson’s Disease Rating Scale

Hoehn and Yahr Classification of Disability¹

​

5

Parkinson’s Disease Background

​

​

• 2nd most common neurodegenerative disease¹
• Chronic progressive disease of the nervous system
• 1 million Americans and 7-10 million people worldwide¹
• 1.5-2 times more common in males than females¹
• Result of basal ganglia dysfunction due to the degeneration of the substantia nigra¹
• The imbalance between dopamine and acetylcholine results in the decreased amplitude of movement that is commonly seen in patients with Parkinson’s Disease¹

​

6

Basal Ganglia Anatomy

The Basal Ganglia is comprised of¹

• Caudate Nucleus
• Putamen Nucleus
• Globus Pallidus Nucleus
• Subthalamic Nucleus
• Substantia Nigra Nucleus

The Substantia Nigra is comprised of¹

• Pars Compacta
• Pars Reticularis

The Substantia Nigra Pars Compacta contains dopamine neurons that inhibit activity in the indirect motor loop of communication between the Basal Ganglia nuclei and the Ventral Posterolateral Nucleus of the Thalamus and the Motor and Premotor Cortices²

​

​

7

https://www.merckmanuals.com/home/multimedia/figure/locating-the-basal-ganglia

Basal Ganglia Function

• The Basal Ganglia is responsible for motor control, execution and regulation of motor function, repetition and initiation of movements as well as action selection and background muscle tone²

​

• The Substantia Nigra communicates with the Thalamus in order to influence motor planning in the Cortex via the indirect motor pathway²

​

• The loss of dopamine neurons in the Substantia Nigra Pars Compacta results in increased activity in the indirect motor pathway which decreases communication with the Thalamus and decreases activation of the cortex, resulting in Parkinson’s Disease^1,2

8

Primary Signs and Symptoms of PD

• Tremor¹
• Rigidity¹
• Akinesia and Bradykinesia¹
• Postural Instability¹

9

Secondary Signs and Symptoms of PD

• Motor function¹
• Motor planning
• Motor learning
• Motor performance¹
• Decreased torque production
• Muscle weakness
• Delayed motor unit recruitment
• Gait¹
• Festinating gait
• Reduced arm swing

10

Non-Motor Signs and Symptoms of PD

• Sensory¹
• Dysphagia¹
• Speech¹
• Cognition¹
• Psychological¹
• Sleep¹
• Autonomic¹

11

LSVT BIG program

• Tailored uniquely to each patient for their goals^3,5
• Designed to treat deficits in movement patterns including:
• Bradykinesia, akinesia, postural control, balance, coordination, stability, gait mechanics^3,5
• Goal
• Teach patients to carry over and sustain bigger movements in ADL’s³
• Methods^3,5
• “Recalibrates” the patient’s sensory perception of movement execution with how the movement appears externally
• Via verbal feedback of movement execution and training of movement perception with task-specific, repetitive, high intensity exercises
• 4 sessions each week for 4 weeks

12

LSVT Big Exercises

• Emphasize “big” movements through exaggeration of normal movement patterns⁵
• Task specific

​

• High repetition of tasks⁵
• Minimum of 15 reps

​

• Sample Exercises⁵
• Sit to stand
• Rock and reach
• Walking with verbal cues

​

13

https://symetricsonline.com/our-services/lsvt-big-program-for-parkinsons-disease/.

​

Discussion Question 1

14

Has anyone worked with a patient with PD or the LSVT-BIG program in the clinic? If so, how did your patient respond to treatment?

​

​

PT Examination

15

Timeline of Treatment

16

Case Description

Mr. V

• 62 year old retired male
• Retired Dentist
• No use of AD
• Lives with active caregiver, wife
• Resides in 1 story home with 8 steps to enter and railing
• Walking access to public transportation

​

No Services Prior to Start of PT for PD

PT Services from July 7, 2022 to August 22, 2022

​

Patient Goals

• Stop shaking and improve balance
• Wants to feel steadier on his feet

​

​

​

​

17

Case Description

Past Medical History

• Thyroid disease, depression, and anxiety
• Family Hx of HTN

​

Patient History of Symptoms

• Feeling off balance and unsteady
• Shakiness or “Shakes”
• Forgetfulness
• No history of falls

​

Chief Complaints

• Feelings of unsteadiness
• Slowed movements
• Peripheral neuropathy
• Claims to have “good” and “bad days”
• Worsening of symptoms during times of stress/anxiety

​

​

​

​

​

18

Current Medications

19

Review of Systems

20

Systems Review

21

Clinical Impression 1

Based upon Mr. V’s complaints and screening, the patient had impairments in observational gait and balance, asymmetrical muscle weakness, decreased vocal strength, and upper extremity tremor, Mr. V presents with signs and symptoms consistent with the medical diagnosis of Parkinson’s Disease made 2 years prior.

​

Examination will include further testing of gait, balance, muscle strength, and coordination

• Berg Balance Scale (BBS)
• Romberg
• 5 Times Sit to Stand (5xSTS)
• 2 minute Walk Test
• 9 Hole Peg Test
• Range of Motion
• Manual Muscle Testing
• Grip Strength

​

​

22

Examination

23

*** MMT and ROM were not formally examined

PT Evaluation

24

Clinical Impression #2

• Results display signs and symptoms consistent with Hoehn and Yahr Stage III Parkinson’s disease.
• Gait and balance deficits
• Generalized lower extremity weakness
• No outside referrals necessary at this time.
• Barriers may include reliance on transportation services to and from therapy.

25

ICF Model

26

Health Condition

Parkinson’s Disease

Body Structures/Function (Impairment)

-Decreased strength

-Decreased balance

-Decreased coordination

-Mild intention tremor

-Increased rigidity

Activity (Tasks)

Abilities

-Sit to stand transfers

-Stair negotiation with 1 railing

Limitations

-Household activities and ADLs (dressing, shaving, bathing)

Participation

Abilities

-Family game nights at home

Limitations

-Unable to participate in long walks with family on the boardwalk

-Unable to drive

Environmental

Internal

-Highly motivated (+)

-Dedicated to therapy (+)

-Stress about PD (-)

External

-Familial support (+)

-PT support (+)

-Familial stress about PD (-)

Prognosis

​

Mr. V has a good prognosis to improve his functional limitations in order to meet his determined goals and increase his quality of life.

​

​

Given Mr. V’s high level of motivation and commitment toward therapy, he was deemed a strong candidate for LSVT BIG.

​

​

Barriers may include his reliance on transportation services to get to therapy.

27

Plan of Care

• One week of standard balance training while updated referral was pending
• Reevaluated for a new baseline
• LSVT BIG set to begin one week later
• 1 hour of therapy 4x/week
• BIG maximal daily exercises (MDE)
• q d on days scheduled therapy days
• BID on days without therapy
• BIG program sessions
• MDE
• BIG walking
• Hierarchical tasks
• Functional component tasks
• Personal hierarchical and functional component tasks determined by Mr. V with PT

28

Short Term Goals (2 weeks)

​

29

Long Term Goals (4 weeks)

30

Interventions

31

Intervention: Standard Balance Program

32

Intervention: LSVT BIG Program

33

*Dosage progression was consistent with HEP progression

*Performed consistently each session

*Treatment addressing these tasks took subjective approach

Outcomes

34

Functional Outcomes

35

Functional Outcomes cont.

36

Functional Outcomes cont.

37

Subjective Outcomes: Assessed on BIG IE

38

Subjective Outcomes: Assessed on BIG PN

39

Discussion

40

Recap: Mr. V

• Mr. V presents with signs and symptoms consistent between stage III and IV Parkinson’s Disease on the Hoehn Yahr Scale
• Tremor
• Rigidity
• Gait deficits
• Kyphosis
• Speech deficits

​

41

Parkinson’s Disease and LSVT-BIG

• Research shows that the best outcomes for people with Parkinson’s Disease are seen with the implementation of the LSVT-BIG program.³

​

• Millage et al., found that 88.9% of patients that received LSVT-BIG training achieved significant differences in at least 1 out of 4 outcome measurements and demonstrated improved function 3 months after termination.³

​

• Hirakawa et al., found that there were short term improvements in outcome measures such as PDQ-39, TUG and 10MWT after the use of LSVT-BIG and that there was a 1 year retention of improvements in QOL, motor symptoms and walking ability.⁴

42

Discussion Question 2

43

What do you think are some factors that led to Mr. V’s success with the LSVT program?

Factors Affecting Mr. V’s Success

• Prior level of function
• Mr. V was independent in all activities and did not rely on the use of any assistive devices
• Medication
• Concurrent use of physical therapy while taking Levadopa/Carbadopa leads to the best outcome results
• Implementation of standard gait and balance interventions
• Mr. V received and additional 4 sessions of standard gait and balance training prior to LSVT-BIG that may have influenced success
• Familiarity with the clinic
• Increased strength and stability

44

Discussion Question 3

​

What do you think are some limitations with the implementation of LSVT BIG?

45

Limitations

Limitations of LSVT treatment:

• Insurance coverage ⁵
• Time commitment from PT ⁵
• Patient adherence to rigor of BIG program and HEP ⁵
• Lack of official maintenance program after 16 sessions ⁵

​

Limitations of Mr. V’s specific treatment:

• LE MMT was not directly measured despite complaints of “feeling weak.”
• Hand dynamometer measurements were not retaken after IE.
• Vitals were not assessed on IE, but were checked when symptomatic.
• Descriptors of “poor,” “fair,” and “good” for assessing balance instead of recording time.

46

Conclusions & Take Home Message

47

• The LSVT BIG program was a successful intervention for Mr. V per his functional and subjective outcomes.

​

• The four standard gait and balance sessions may have been beneficial for Mr. V to become familiar to the clinic, build trust with therapists, and begin therapeutic activities before the LSVT program.

​

• Parkinson’s Disease is a common disease in America, and the LSVT BIG program may be an effective method for patients to maintain their strength and combat symptoms.^{1, 3}

​

• Future research needs to evaluate the best way to maintain progress developed by the BIG program following its implementation.⁵

Thank You

Dr. Solfanelli

DPT Faculty and Staff

Fellow PT Students

48

Appendix- Clinometric Details for Pts with PD

49

References

50

1. O'Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation. 7th ed. Philadelphia: F. A. Davis; 2019.
2. Lundy-Ekman L. Neuroscience: Fundamentals for Rehabilitation. 5th ed. St. Louis, MO: Elsevier; 2018.
3. Millage B, Vesey E, Finkelstein M, Anheluk M. Effect of gait speed, balance, motor symptom rating, and quality of life in those with stage I parkinson’s disease utilizing LSVT BIG. Hindawi Publishing Corporation Rehabilitation Research and Practice. 2017. Doi: 10.1155/2017/9871070
4. Hirakawa Y, Koyama S, Takeda K, Iwai M, Motoya I, Sakurai H, et al. Short term effects and its retention of LSVT BIG on QOL improvement: 1 year follow-up in a patient with Parkinson’s Disease. Neuro Rehab. 2021;49(3) 501-509. Doi: 10.3233/NRE-210129
5. Fox C, Ebersbach G, Ramig L, Sapir S. LSVT loud and LSVT BIG: Behavioral treatment programs for speech and body movement in parkinson disease. Parkinson's Disease. 2012;2012:1-12. doi:10.1155/2012/391946
6. Understanding Possible Side Effects. www.synthroid.com. Updated January 2020. Accessed November 8, 2022. https://www.synthroid.com/starting/synthroid-side-effects
7. Mirtazapine: MedlinePlus Drug Information. medlineplus.gov. Updated January 15, 2022. Accessed November 8, 2022.

https://medlineplus.gov/druginfo/meds/a697009.html

• Paroxetine: MedlinePlus Drug Information. medlineplus.gov. Updated January 15, 2022. Accessed November 8, 2022.

https://medlineplus.gov/druginfo/meds/a698032.html#:~:text=Paroxetine%20is%20in%20a%20class

• Ciccone CD. Pharmacology in Rehabilitation. (Updated 5th ed.). Philadelphia, PA: F.A. Davis Company; 2022
• 1. Evans LE, Cheeseman MD, Yahya N, Jones K. Investigating Apoptozole as a Chemical Probe for HSP70 Inhibition. Sherman M, ed. PLOS ONE. 2015;10(10):e0140006. doi:10.1371/journal.pone.0140006
• Perterka M, Odorfer T, Schwab M, Volkmann J, Zeller D. LSVT-BIG therapy in Parkinson’s disease: physiological evidence for proprioceptive recalibration. BMC Neurology. 2020;20(276). doi:10.1186/s12883-020-01858-2
• Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the Unified Parkinson Disease Rating Scale in people with parkinsonism. Phys Ther. 2008;88(6):733-746. doi:10.2522/ptj.20070214
• Duncan RP, Leddy AL, Earhart GM. Five times sit-to-stand test performance in parkinson's disease. Arch Phys Med Rehabil. 2011;92(9):1431-1436. doi:10.1016/j.apmr.2011.04.008
• Paul SS, Canning CG, Sherrington C, Fung VSC. Reproducibility of measures of leg muscle power, leg muscle strength, postural sway and mobility in people with parkinson's disease. Gait & Posture. 2012;36(3):639-642. doi:10.1016/j.gaitpost.2012.04.013

​

Questions?

51