Effect on Gait Speed, Balance, Motor Symptom Rating, and Quality of Life in Those with Stage I Parkinson’s Disease Utilizing LSVT BIG®

Individuals with Parkinson’s Disease (PD) are often not referred to Physical Therapy (PT) until there are issues with mobility in later Hoehn and Yahr Stages. There have been no studies outlining the benefits of PT intervention in Stage I only. For persons with PD, deficits in motor function increase over time due to destruction of dopamine-producing cells. LSVT BIG, an exercise program for PD, has been shown to be effective in improving mobility. The purpose of this study was to assess participants functional improvement at a level of minimal clinically important difference (MCID) in one of four outcome measures: Gait Speed, Berg Balance Assessment, Functional Gait Assessment, and Unified Parkinson’s Disease Rating Scale Motor Section.Case Description. Nine participants with Stage I PD received LSVT BIG 4x/week for 4 weeks followed by bimonthly participation in a community class. Outcome measurement occurred at baseline, after LSVT BIG, and three months after LSVT BIG. Outcomes. Eight of nine participants (88.9%) achieved MCID in at least one of the four measures at both after and 3 months after LSVT BIG training indicating improvement based on our criteria. Participants in Stage I of PD in this study completed LSVT BIG and demonstrated improved function.

For persons diagnosed with Parkinson’s Disease (PD), deficits in motor function increase during the course of the disease, intensifying disability. These deficits are the result of loss of dopamine-secreting neurons in the motor circuits of the basal ganglia which are essential for control and coordination of movement [1]. This degeneration manifests as the cardinal motor features of PD: bradykinesia, resting tremor, rigidity of muscles, and impaired posture [2]. There is evidence that exercise is neuroprotective and, if done regularly, can help the brain produce growth factors to protect dopamine-producing neurons from early death [3]. Animal studies have indicated that increased use of a limb can reduce neurotoxins, thereby preserving dopamine neurons, and potentially slowing or temporarily halting progression of motor deficits related to PD [4]. This is important for those in early Hoehn and Yahr Stages of PD where unilateral involvement can cause functional limitations and asymmetrical movements or compensatory movement strategies.

A comprehensive exercise approach in treating PD used in Physical and Occupational Therapy is the “Lee Silverman Voice Treatment (LSVT) BIG”. This approach was developed and evaluated by Drs. Becky Farley and Gail Koshland. It began as a concept of “Learning and Training BIG” based on principles first described and researched for LSVT LOUD®, where the primary treatment focus was amplitude [5]. Individuals with PD tend to overestimate their ability to complete tasks with the proper amplitude, inaccurately perceiving their movements to be appropriate in size and strength. They often do not step, reach, or walk far enough without visual or verbal feedback [56]. LSVT BIG is designed to treat specific symptoms related to these deficits in movement patterns including bradykinesia or akinesia, decreased postural control and awareness, decreased gait mechanics and stability, and decreased balance [5]. The goal is to teach participants to carry over and sustain bigger movements in their daily activities [6]. The effect of BIG is achieved by targeting damaged basal ganglia through repetitive activation across motor regions in the brain that are involved in normal amplitude movements [357]. An effort scale helps participants learn to calibrate their movements to overcome the sensory mismatch between perceived movement and the actual completed movement. The LSVT BIG approach is unique in incorporating shaping techniques through use of therapist modeling or tactile/visual cues, improving self-perception and leading to improvement in movement patterns [1].

LSVT BIG has been shown to be effective in improving mobility for people with PD in a variety of stages of the disease [1612]. There are have been studies that have investigated LSVT BIG and the effectiveness, but all are focused on multiple Hoehn and Yahr Stages of PD. Most research articles focus on Hoehn and Yahr Stages I–III with no studies focused solely on Stage I [12]. These individuals are not often referred for PT interventions until they or their care partner note severe issues with mobility [5]. Therapy referrals are often reactive rather than proactive in managing secondary impairments of PD. For example, referrals may occur when individuals develop postural instability and decreased muscle strength which leads to falls and increased risk of morbidity and mortality [13]. Drug therapies and surgical interventions have been shown to provide symptomatic relief; however, even with these interventions, motor deficits continue to progress during the course of the disease [6]. Exercise has been previously established in a number of studies to be an adjunct therapy to medication, which may provide even more benefit. Previous studies that included participants in Hoehn and Yahr Stages I to III found that improvements in amplitude and speed were greatest in Stage I for reaching and gait [12]. Those in Stage I do not always complete normal movement patterns, leading to early nonuse and further degeneration, implying that individuals in Stage I can potentially realize significant gains from BIG training [12].

The primary purpose of this study was to explore how LSVT BIG can impact individuals in Stage I of PD. Care providers need evidence that referral at early stages to a PT program such as LSVT BIG is beneficial [814]. Currently, there are no known studies that focus exclusively on this subset of PD patients. A secondary objective was to explore adherence to exercise recommendations to better assist in prescribing exercise that can be completed through the lifespan.