My OT Story: How LSVT BIG Radically Shifted My Practice

My OT Story: How LSVT BIG Radically Shifted My Practice

By Erica Vitek MOT, OTR, BCB-PMD, PRPC

Group of paper airplane in one direction and with one individual pointing in the different way.

Occupational therapists (OTs) new to treating people with Parkinson’s disease (PD) may find it challenging to know how to intervene with the best techniques for optimal functional results.  People with PD usually describe a complex array of motor, sensory, cognitive, and autonomic impairments during the initial evaluation. Many people with PD have been seen by other OT providers in the past without success and have even been told there is nothing they can do to help to slow the progression of their symptoms or improve their function. These factors can cause resistance to an OT’s intervention even before treatment has started.

To have a successful partnership then, it is important for the OT to establish their skill and achieve quick buy-in from the patient. People are naturally more motivated to participate in therapy when they can see immediate proof that they will be able to improve their function and achieve their goals. Additionally, OTs want to develop a strong rapport and positive relationship so they can continue to support their patients with PD as PD progresses. But how do you do this?

This is my story as an OT whose practice was radically shifted as a result of LSVT BIG®.

My Experience Before LSVT BIG

Remembering back to when I was a newly licensed occupational therapist (OT), I passed my boards and stepped into a job that required me to treat an entire acute care caseload of people with Parkinson disease (PD).  Learning about PD from a professor in OT school and reading about it in textbooks did not even begin to scratch the surface for what I was about to encounter.  I quickly learned that my patients’ experiences with this neurological condition were all very unique.

The physician I worked with at the beginning of my career admitted his patients with PD to the hospital for monitored medication adjustments.  This was a common practice in my area at that time.  In acute care, you have only a very short window of time to impact functional performance in a meaningful way.  Your rapport and therapeutic relationship have not had enough time to be established.  The patients’ flat affect does not give you typical feedback which tells you if they are receptive to your education and techniques.  They may appear frail with stooped posture, shuffling gait, slow or small movements, and have difficulty getting up from a chair just to name a few.

My interventions were largely compensatory in nature, and much of the time I saw patients who had advanced disease.  I focused on issuing adaptive equipment, for example, a dressing stick, reacher, or sock aide.  When training patients how to use these devices, my success rate varied, but most often I found my patients with PD had difficulty sequencing the task, coordinating their movements and learning how to use the tool to do something as simple as get their pants or socks on.

I had also developed a “freezing kit” which included a variety of external cueing devices (metronome, laser light, tape to put lines on the floor etc.) that I could use to help my patients overcome mobility challenges which were impacting their occupational performance.  In addition, I would also work on strengthening of the fine motor muscles of the hand in hopes of improving their ease in fastening buttons, opening food containers, managing medications, and writing.

Unfortunately, I did not have the effectiveness and carryover I desired for my patients, which frustrated me and likely discouraged my patients.  I was looking for an intervention that would stick. 

And then, I found LSVT BIG®.  I attended the two-day training in 2009, and my perspective on working with someone with PD completely changed. I began to see that I could have an immediate and profound impact on my patients with PD and other neurological conditions.  Simple, direct cues to make specific movements “bigger” allowed me to see that my patients with PD could actually overcome their classically small, slow movements. Despite the individuality of my patients and the variety of tasks they were practicing, whether it be dressing, showering, making a meal, or getting in and out of bed, applying amplitude and bigger effort to those tasks dramatically changed their performance.  They could complete the desired task more independently and in record time.  I saw that my patients with PD really could move!  I was finally making an immediate and lasting impact, and I was empowering my patients at the same time to take charge of their symptoms.

The Most Important Principles I’ve Learned Through LSVT BIG

LSVT BIG has changed my entire practice as an OT.  I moved from acute care into outpatient hospital-based care.  This has allowed me to provide the entire four-week LSVT BIG protocol to solidify immediate results into lasting results. I have learned how to incorporate key principles that drive neuroplasticity, or “brain change” into my treatments.  A few of these principles used in LSVT BIG are:

  1. Earlier is better. More and more of my patients are receiving therapy soon after diagnosis.  This is important, because it gives us the opportunity to optimize function, establish exercise habits and educate while symptoms are still mild. There is also potential to actually improve brain function when the underlying pathology is not so severe.
  2. Practice repetitively. Like with any skill we want to learn, the more we practice the better.  People with PD need higher levels of repetition of practice to learn and retain skills.  In LSVT BIG, we practice many things, such as getting up from a chair, several hundred times over the course of a month!
  3. Exercise intensively. The LSVT BIG exercises and protocol is not easy.  My patients work up a sweat, and so do I! I push them because I know that they are usually NOT frail, and because exercise is important not only for their physical health (muscles, joints, heart), but also for their brain health and symptom management.
  4. Make it meaningful. As OTs, the core of our training is the use of “occupation”, or important daily activities that occupy our time, as our treatment modality.  Research has shown that practicing things important to us drives brain change.  Sometimes we are guilty of practicing tasks and exercises which have no direct link to function for our patient.  To motivate patients during LSVT BIG delivery, it is key to deepen your understanding of which tasks THEY would like to be able to do better. Taking a look at how they are performed will be key to working on these tasks while implementing the use of “bigger” movements. For some patients, it is a hobby like fishing or dancing, and for others, it is a basic skill like putting on a jacket or turning over in bed.

caregiver and senior woman, 90 years old, both embracing eack other, happy together smilingWhat I love most is the relationships I build with my patients who receive LSVT BIG.  These relationships do not end after the four weeks of therapy is over. I initially help them learn how to implement their bigger movements into daily life, and I help them to get in the habit of long-term daily exercise and functional practice. They can do this either on their own, with a caregiver, or through a community class, such as BIG for LIFE®. I also schedule regular “tune ups” with my LSVT BIG patients so they are continually supported and monitored over time.

If you are an OT who wants to do more to help your patients with PD and other neurological conditions, I would say this to them: LSVT BIG opens the door to movement capabilities that your patients may have thought were lost.  You will learn to be your patients’ guide in this discovery.  Your patients will light up with excitement about their capabilities when you show them that they still can do the things they thought their body would no longer allow them to do because of PD.

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Erica Vitek, Author

About the author:


Ms. Vitek received her Master’s in Occupational Therapy from Concordia University in Wisconsin. She is employed by Aurora Sinai Medical Center in Milwaukee, WI, where she is the LSVT program lead and runs LSVT BIG and LSVT LOUD skills classes for LSVT graduates.  Ms. Vitek is a graduate of the NPF’s Allied Team Training for PD and has been certified in LSVT BIG since 2009. Ms. Vitek is Board Certified in Biofeedback for Pelvic Muscle Dysfunction and a Certified Pelvic Rehabilitation Practitioner allowing her to address bladder, bowel and sexual dysfunction in her patients with PD. Additionally, she is a faculty instructor with Herman & Wallace Pelvic Rehabilitation Institute and authored the course Parkinson Disease and Pelvic Rehabilitation.  She regularly presents and authors articles for the Wisconsin Parkinson Association.