The Science and Practice of LSVT BIG Mohabbat

The Science and Practice of LSVT BIG Mohabbat Ali Sr. Physiotherapist & coordinator SRC

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)

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

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

“If only we can hear and understand her” Family of Mrs. Lee Silverman 1987

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

20+ year journey from invention to intervention Phase IV, V Phase III Phase I, II Over 8 million dollars in NIH funding 1987 -89: Initial invention; Pilot data (Scottsdale) 1989 -91: Office of Education OE-NIDRR 1991 -94: OE-NIDRR 1990 -95: NIH funded RCT Efficacy 1995 -00: NIH funded EMG, Kinematics 2002 -07: NIH funded RCT Spread of effects 2007 -12: NIH funded RCT, imaging 2001 -02: Coleman Institute (PDA; LSVTC) 2002 -04: NIH and M J FOX Foundation PDA (R 21) 2002 -04: Coleman Institute (VT; LSVTVT) 2004 -06: NIH LSVTVT (R 21) 2004 : Coleman Institute (LSVT Down Syndrome) 2004 -07: LSVT –Dissemination 2006: Technology-enhanced Clinician Training (SBIR) 2010: Technology-enhanced LSVT LOUD delivery (SBIR Copyright LSVT Global, Inc. 2011

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)

TARGET of LSVT LOUD Loud is more than a laryngeal event – spread of effects LOUD SOFT HEALTHY LOUDNESS

CALIBRATION Learning i ry o s sen m, e l b g o n i pr e cu l a n r e t n

LSVT LOUD LSVT BIG (Farley & Koshland, 2005; Farley, Fox, et al. , 2008; Farley & Koshland, in revision)

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

TARGET BIG (Large amplitude whole body movement) Single Target - Triggers Activation across motor systems SMALL BIG NORMAL “BIGNESS“

MODE Delivery – 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)

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!!”

CALIBRATION Learning ory s n rn se a n e i l a Retr ion and s for ue rt and rat c b l i l a ca tern ent effo n i new ovem s al m bignes m r no

Impaired self-perception Deficits in internal cues Small movements reduced amplitude of output

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

Treatment Session Daily Exercises 1. Floor to Ceiling 2. Side to Side 3. Forward step 4. Sideways step 5. Backward step 6. Forward Rock and Reach 7. 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

Daily Whole-body Maximal Amplitude Exercises Multidirectional Sustained Movements Floor to Ceiling Side to Side

Daily Whole-body Maximal Amplitude Exercises Multidirectional Repetitive Movements Sideways Backwards Forwards

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 & turn Stand & turn Sit to stand BIG

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

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

Objective Outcomes: PRE Falls Assistive device Confidence Gait Velocity % of age matched norm Endurance 1 -2/month Cane 37. 5% 0. 35 m/s 29. 6 % 730 ft POST 0/month None 56. 8% 1. 17 m/s 100% 1200 ft

Bernie’s Goals ü To improve his walking ü To go to the movies ü To play with his grandchildren ü To go out to dinner with friends and family ü All accomplished to his satisfaction!

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

Walking Improvements Faster TRAD Absolute Change (cm/sec) 12 Better BIG 10 8 6 4 2 0 1 -month T 4 -T 1 3 -months T 12 -T 1 Preferred Stride Length Absolute Change (cm) Preferred Velocity 14 Bigger 14 12 10 8 6 4 2 0 T 4 -T 1 1 -month T 12 -T 1 3 -months Improvements occurred in both groups and lasted 3 months. Farley & Koshland, in preparation (Unpublished data)

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

Conclusions: • Activity Matters • LSVT BIG may be especially important for trunk rotation and balance - everyday movements

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

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. ”

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

PWR! Hands

PWR! Reach

PWR! Reach

PWR! Reach

PWR! Rock

PWR! Rock

PWR! Twist

PWR! Step

PWR! Turn

overview of one session Maximal Daily Exercises Sustained Movements 1. 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)

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

Maximum Daily Exercise Tips: • Daily exercises don’t change over 4 weeks 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”

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

“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”

Thank you for your attention! Questions & Comments