Emerging Research on the Use of LSVT BIG® in People with Chronic Stroke

Have you ever wondered if LSVT BIG could be helpful to more than just people with Parkinson’s disease? For example, people post-stroke? Because one in six people worldwide will have a stroke in their lifetime, finding effective rehabilitation interventions is of the utmost importance.

Drs. Whitney Henderson and Rachel Proffitt, Assistant Professors in the Department of Occupational Therapy at the University of Missouri, in Columbia, Missouri, are among the first researchers to investigate this topic. Together, they wrote a case study titled “Lee Silverman Voice Treatment BIG^® for a Person with Stroke”, published in the American Journal of Occupational Therapy in 2018. Since that time, they have completed a second case study and are now recruiting patients for a larger trial.

Read our interview below to learn more about the inspiration for this work, their current research and future directions.

How did you start this line of research?

WH: I first learned about LSVT BIG when completing my clinical doctorate. We were discussing various treatment approaches in an evidence-based practice course. I further reviewed the treatment and took the online training a few months later.

RP: Whitney came into my office one day in 2016, a few months after I had started as faculty at the University of Missouri. She described the intervention to me and the theories that guide it. She said that she wanted to try it out with an individual post-stroke. I said, “Great, why do you need me?”.

WH: At the same time, I was treating few clients with PD in our clinic using LSVT BIG and revising a course that included treatment approaches for individuals with neurological conditions. I saw several similarities between the information I was preparing for class and the evidence and theory supporting LSVT BIG. I randomly asked a client with a stroke to “move big” and she was able to move better. I further discussed the protocol with this client saying “I have no idea if this is going to work for you, but I think it can.” She enthusiastically replied, “When do we start?”.

RP: After we decided to move forward with this, I helped get all of the “research” components in place: IRB approval, impartial assessor for our outcome measures, data storage.

Can you give us a bit of background on the first four clients you treated with LSVT BIG for their chronic stroke symptoms?

WH: Our clients have been very different. Of the four, we have completed standing exercises with two clients and a combination of seated and standing with two clients. With the two clients that completed the combination, we were able to progress each one to complete more exercises and tasks in standing by the end of the four weeks. With the two that completed exercises in standing, we were able to grade exercises up in a variety of ways including increase number of repetitions, use of weights on upper extremities, balance challenges, such as stepping on or over a foam wedge. Two of the four clients experienced expressive aphasia, which did not appear to impact treatment. Each of the five clients had varying degrees of tone throughout upper extremity ranging from areas of no tone to moderate tone. Each of the clients had a supportive family member to assist with transportation as only two of the four were able to drive. They each had a wide variety of occupations they desired to perform better in their everyday lives including work, leisure, Instrumental Activities of Daily Living, and Activities of Daily Living.

What were some of your initial findings in these case studies? 

RP: We were blown away by our first two case studies. The first individual described her progress as a “snowball effect”. Every week, and even every day, she reported being able to do more and more in her everyday life. She started using her left hand to grab the seatbelt, returned to swimming, gardening and was effectively using her left arm and hand in her work at her restaurant.

Another client was able to feed his pets and hold and feed his new (and first) grandchild and began noticing improvements in ability to walk in physical therapy after the intervention was completed. His wife felt comfortable leaving him home alone for the first time since his stroke.

Were there any surprises or key things you learned? 

RP: The changes we saw with our second case study participant affected not only him but his family. His wife reported that she also had a complete shift in her attitude towards rehabilitation and what to expect in terms of recovery and function. When I interviewed her after the study was over, both of us were crying at the end!

WH: As Rachel mentioned, the psychosocial (qualitative) impact this treatment has had with individuals with stroke has been surprising. I am so amazed at how the little changes we start to notice by the end of week one completely change their demeanor. They become more motivated because of the results they are seeing further impacting their function and quality of life.

How did LSVT BIG impact these patients in a way that traditional therapy had not?

WH: All of our clients have participated in therapy for months and years. They all experienced various benefits from those interventions, but with LSVT BIG, the improvements in movement just seem to happen more quickly, and those improvements carried over to their everyday lives.

We often saw changes in the way each of these clients moved by the end of the first week. For example, for over a year, I had worked with a client on moving her thumb out of her palm so she could better open and close her hand. At the end of the first week of LSVT BIG, she was able to extend and keep thumb on outside of hand during daily tasks and it hasn’t moved back into her palm since that time. Another client often has to shake hands at his family business. By the seventh session his hand was actively opening to shake hands.

Another difference I have noticed is the motivation piece. By the end of the first week, the client and the family member often have a huge list of daily tasks they want to try at home for their carryover assignment. They often go above and beyond and try a lot of different things; especially the days when they aren’t with us for treatment. Lastly, as we mentioned above, with these changes in movement and participation, they just seem to have improvement in psychosocial well-being.

Where are you now with your LSVT BIG research?

RP: I was awarded an Intervention Research Grant from the American Occupational Therapy Foundation to investigate the preliminary effect of LSVT BIG in chronic stroke. We have been conducting that study over the past year. Recruitment has been very challenging as many individuals post-stroke do not drive and have difficulty committing to the intensive program. We serve a rural community here in Columbia, MO and this introduces challenges we were not anticipating.

What do you hope to continue to study in the future?

RP: We plan to explore a tele-health delivery of part of the LSVT BIG intervention. As an occupational therapist, I feel strongly about building evidence for interventions that are effective and I believe that LSVT BIG has the potential to significantly improve the lives of individuals post-stroke. And like the OT that I am, it may mean that we have to adapt customize our approach to ultimately meet the needs of our clients.

Summary

While the research on the use of LSVT BIG in people stroke is just beginning, the need for effective therapy interventions to help stroke survivors optimize their function in daily life is on the rise. The built-in principles which drive neuroplasticity (brain change) and the function- based approach which emphasizes carryover to everyday tasks may indeed be helpful for a number of conditions beyond PD. We are appreciative of hard-working and passionate researchers like Dr. Henderson and Dr. Proffitt who are pioneers in exploring this new question.