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!

Basic science evidence for the value of
exercise in PD (classically drugs, surgery,
today…)

Identified key principles of exercise that
drive activity-dependent neural plasticity

Demonstrated that exercise can improve
brain functioning (neural plasticity) and
may slow disease progression

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 (R21)
2002-04: Coleman Institute (VT; LSVTVT)
2004-06: NIH LSVTVT (R21)
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
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
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 & 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
To improve his walking
To go to the movies
To play with his grandchildren
To go out to dinner with friends and family
All accomplished to his satisfaction!
LSVT BIG
vs.
Traditional Outpatient Physical Therapy
Randomized Comparative Pilot Study
Matched Frequency/Duration
4X/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
Preferred Stride Length
BIG
12
TRAD
Absolute Change
(cm/sec)
14
Better
10
8
6
4
2
0
T4-T1
1-month
T12-T1
3-months
Absolute Change (cm)
Preferred Velocity
Bigger
14
12
10
8
6
4
2
0
T4-T1
1-month
T12-T1
3-months
Improvements occurred in both groups and lasted 3 months.
Farley & Koshland, in preparation (Unpublished data)
Trunk Rotation
BIG
Trunk Rotation
TRAD
Absolute Change
Better
30
P < .05
P < .05
25
20
15
10
5
0
T4-T1
-5
1-month
T12-T1
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
 Combined or “Hybrid” approach for PD
 May promote greater plasticity through greater
intensity, complexity, saliency
 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, 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 10s
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, 2sets of 20
5. Rock and reach side to side, 2 sets of 20 Functional
Movements ~3-5 exercises that are patient driven, repeat 10x
Ex: Rolling, supine to sit, STS, walk and turn, Sit and reach,
stand and reach, walk and pick up object
Maximum Daily Exercise Tips:
• Daily exercises don’t change over 4weeks 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