THINK BIG!
EXERCISES FOR
INDIVIDUALS WITH
PARKINSON’S DISEASE
Betty MacNeill, PT, DPT
January 2013 SED Meeting
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PRESENTATION
OBJECTIVES
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Identify the symptoms of Parkinson’s
disease (PD) that benefit from exercise
interventions
Identify both traditional and nontraditional therapeutic models for
managing the symptoms of PD
Define and discuss the basic philosophy
associated with the LSVT-BIG intervention
model
Identify and discuss the 4 fundamental
treatment concepts of the LSVT-BIG model
Describe the basic exercise protocols
associated with LSVT-BIG and provide a
rationale for each
Develop confidence in applying some LSVTBIG techniques and principles with selected
patient populations
PATHOPHYSIOLOGY/ETIOLOGY
Pathophys: Loss of dopanergic cells in the
substantia nigra leads to a deficiency in
dopamine for use by the communication
pathways in the
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basal ganglia, which are critical to producing normal
movement and postural control, and
neural circuits to the frontal lobe, which are critical
for mental processing, motor planning, and
personality.
PARKINSON’S DISEASE
Classical Clinical Features =
TRAP
• Tremor, resting
• Rigidity, cogwheel
• Akinesia, bradykinesia
• Postural Instability
COMPREHENSIVE LIST OF SYMPTOMS IS MUCH
MORE HELPFUL FOR UNDERSTANDING THE
FULL SPECTRUM OF THE CHALLENGES FACED
BY INDIVIDUALS WITH IPD
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See handout for further explanations
Motor symptoms (in addition to the 4 Cardinal Signs of PD):
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Micrographia, Speech difficulties, Lessened facial expression
& smiling, Swallowing difficulties, Decreased blinking and the
appearance of staring, Low back pain or ache accompanied by
poor posture, Cramps or a burning sensation in thighs or legs,
Lack of arm swing on the affected side, Episodes of feeling
"stuck in place" when initiating a step (so called "freezing"),
Slight foot drag on one or both sides
Non-motor symptoms:
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Loss of smell, Feelings of hot or cold, excessive sweating, oily
skin, increased dandruff, Sleep Disturbances, Depression
and/or anxiety, Decreased “executive function”, Dementia,
characterized particularly by decreased memory for recent
events
STAGES OF DISEASE PROGRESSION
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Modified Hoehn and Yahr Staging
 Stage 0 = No signs of disease
 Stage 1 = Unilateral disease
 Stage 1.5 = Unilateral plus axial involvement
 Stage 2 = Bilateral disease without impairment
of balance
 Stage 2.5 = Mild bilateral disease with recovery
on “pull test”
 Stage 3 = Mild to moderate bilateral disease;
some postural instability; physically
independent
 Stage 4 = Moderate to severe bilateral disease;
frequent loss of balance; 50% physically
dependent
 Stage 5 = Non-ambulatory; 80-100% dependent
for ADL’s
Exercise Considerations
 Who
should exercise?
 How much exercise?
 Which symptoms and/or movement
challenges are affected by exercise (if any)?
PHYSICAL THERAPY MANAGEMENT –
EXERCISE CONSIDERATIONS
 General
guidelines do not differ much from
those applied to other patient diagnoses. Make
decisions for treatment interventions based on:
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Impairments, functional limitations, and disabilities
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consider for patients with IPD:
Timing of optimal effect of medications
On/Off phenomena (Clinical fluctuation)
Unique characteristics of postural and gait
disturbances
Effects of aging
Concurrent pathologies
PHYSICAL THERAPY MANAGEMENT –
SUMMARY OF HANDOUT RE: EXERCISE MODELS
 Many
different and effective models are
available for helping patients with PD exercise
 For best results, the patient must exert an
“effort” and be motivated to perform multiple
repetitions on a daily basis
 Marketing “Exercise as Medicine” is a good way
to encourage patient involvement and explain
the neuroprotective qualities of adequate
exercise
 Emphasis for tonight, however, is on the LSVTBIG Model for Intervention
WHAT IS “LSVT* – BIG”?
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Definition: Intensive amplitude-based exercise program for
limb motor system
Background: Founded upon the principles of LSVT* LOUD , which is an intensive amplitude-based exercise
program for speech motor system
Main premise: With exaggerated exercise movements, the
patient will learn to use their bigger movements
automatically in everyday life
 Better posture
 Better flexibility
 Better movements
 Better balance
*LSVT = Lee Silverman Voice Therapy (www.LSVTglobal.com)
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
1.
Emphasis on AMPLITUDE is first
2.
SENSORY Calibration is second aspect
3.
The exercise program must be INTENSIVE
4.
a.
High physical and mental effort
b.
Dosage/repetition/difficulty
Quantification/Empowerment is necessary for follow
through
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
AMPLITUDE
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Defined as the largest range of motion that can be
performed with the highest effort with the most
maximally efficient biomechanics every trial / every
day
Patients must be approached with high expectations
on a regular basis.
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Requires vigilance from clinician and patient
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
SENSORY CALIBRATION OR RETRAINING
Defined as the process of teaching the patient to
self-monitor and to accept that what feels “too
big” is really WNL
 Important for therapists to give feedback about
normalcy
 Calibration is at the heart of the matter:
 Retrain faulty sensory perceptions
 Establish new associations between effort and
normal movement
 Create new motor memories (BIGGER plans)
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LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
INTENSIVE EFFORT
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Full exercise program has a standardized protocol
Prescribed dosage and method of delivery include:
a. Frequency: 16 1-hr individual sessions;
4x/week
b. Duration: 4 weeks
c. Strength: High effort
Practice and repetition are essential ingredients to
provide the neural protection and up-training benefits
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
QUANTIFICATION/EMPOWERMENT
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Key is to motivate patient with feedback, because
the expectation is that individuals with PD can
get better!!!!
REQUIREMENTS:
1) Push the patient to generate high effort
2) Reinforce! Motivate!
3) Empower with potential
4) Document outcomes
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
FEEDBACK GUIDELINES FOR THERAPISTS
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DRIVE BIG EFFORT: Best model for teaching – “Do
what I do” (minimizes cognitive load)
SHAPE: Optimize alignment first through tactile,
visual, auditory, and proprioceptive cues
STABILIZE WITH FEEDBACK: Reinforce, practice
and motivate the individual’s own actions. Patients
with PD need more reinforcement/motivation than
others
CALIBRATE: Retrain sensory perceptions – effort
must feel BIG in order to look NORMAL
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
SHOULD BE 50-60 MINUTES PER DAY
I. MAXIMAL DAILY EXERCISES
1. Multidirectional Sustained Movements (2)
2. Multidirectional Repetitive Movements (5)
3. Functional Movements (1-5 depending on
patient)
II. HIERARCHY TASKS (Includes ADL’s)
III. CARRYOVER ASSIGNMENTS
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
DEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES
1. Multidirectional Sustained Movements (2)
Purpose of Exercises: Sustained muscle
activation and active stretching.
A. Floor to ceiling stretch in sitting
B. Side to Side stretch in sitting
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NOTE: 10-20 secs. would be the average sustained time. A
“hand flick” can be added when the patient is able to
sustain the position achieved.
EXAMPLES OF “MULTIDIRECTIONAL SUSTAINED
MOVEMENTS” WITH AN EXERCISE GROUP
End position for the
“floor to ceiling”
stretch in sitting
“Side-to-side” stretch
with modification
of hand placements
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
DEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES
2. Multidirectional Repetitive Movements (5)
Purpose of these exercises:
Differentiating starting and stopping
Changing directions
Sequential endurance
Balance
Strengthening
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
DEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES
2. Multidirectional Repetitive Movements (5)
A. Step and Reach (3)
1) Forwards
2) Sidewards
3) Backwards
B. Rock and Reach (2)
4) Forward / Backward
5) Side to side
EXAMPLES OF “MULTIDIRECTIONAL
REPETITIVE MOVEMENTS” WITH EXERCISE
GROUP
Sidewards
Step & Reach
Forward Step
and Reach
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
ADDITIONAL DAILY ACTIVITIES
II. HIERARCHY TASKS (Includes ADL’s)
Purpose of exercises/tasks:
Overlearn familiar commonly-used and
salient everyday movements
Reminder for BIG movements at home
Encourages compliance and carryover
Requires task analysis for maximal benefit
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
ADDITIONAL DAILY ACTIVITIES
HIERARCHY TASKS:
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Rolling
Sit to Stand
Walk & Turn
Everyone needs
these, but there is
some flexibility
associated with
personal choice
Other Examples:
Floor to Stand
Getting out of bed
Sit & reach
Stand & reach
Walk & reach
Stand & turn
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
ADDITIONAL DAILY ACTIVITIES
III. CARRYOVER ASSIGNMENTS
What are they? Assignments the PT mandates to implement “bigness” into real life. They
must fit into the patient’s daily living activities
for that day, so they change on a regular basis.
Examples:
BOTTOM LINE
Think and Act BIG
Because if you don’t use it,
then you’ll lose it!