The principles behind a successful speech therapy for patients with Parkinson’s disease are now being applied to a new therapy approach for this patient group and others.

The original LSVT (Lee Silverman Voice Treatment) Loud program was founded 15 years ago and helps participants enhance sound and articulation by speaking at an exaggerated volume. LSVT Big uses that same idea of exaggeration, asking occupational therapy participants to make exaggerated motions.

“It’s kind of like tai chi, but it’s accelerated,” says the inventor, Becky Farley, PT, PhD, a research assistant at the University of Arizona. “It trains for both speed and amplitude.”

Occupational therapists say patient outcomes of the therapy are positive. “It truly can change someone’s life,” says Wendee Brosig, OT, regional rehab consultant for Foundation Management Services in Lubbock, Texas. “We are seeing amazing changes and results in patients in the home.”

One recent Parkinson’s patient in an assisted-living facility had an up-and-go time of 68 seconds, Brosig says. After intense LSVT Big training, his time to get up and move forward was only 28 seconds. “That’s a 40-second impact,” Brosig says. “The therapy really frees them up.”

Mirroring Movements

In LSVT Big, patients mirror their occupational or physical therapist in a series of big movements, such as reaching toward the ceiling and the floor with their arms, rotating at the waist, stepping out in lunges and stretching their arms in all directions. After the series, the OT works with the same principles on a goal of the patient, such as emptying the dishwasher or doing the laundry.

The protocol is intensive and complex, with many repetitions of core movements that are used in daily living. The schedule for the intense therapy is one hour, four days a week for four weeks, in individual one-on-one sessions with an OT or PT.

The therapy can be delivered to patients either standing or, if unable to stand, in a sitting position, Farley says. In a new exercise gym that Farley developed for Parkinson’s patients, some patients do LSVT Big suspended in a harness so they will not fear falling, she says.

“It teaches people a strategy that they can take anywhere,” Farley says. “It has both an internal and external cue — patients can be told verbally to ‘think big’ by family members, caregivers or any home healthcare providers. It can go with you.”

Brosig says the philosophy behind LSVT Big is counter to what OTs learn in school. “In school, we were taught that Parkinson’s was almost fatal and that all we could do was a lot of compensation for what was happening to them,” she says. “With LSVT Big, you’re asking patients to be bigger with every movement.”

LSVT Big therapy works on all stages of the disease, from early onset to later stages, Brosig says. In addition, she’s been able to use the therapy on patients with other neurological disorders, including stroke and multiple sclerosis.

Sheila J. Mendon, OTR/L, HTC, of Casa Colina Hospital, in Pomona, Calif., says LSVT Big moves can easily translate to the functional tasks of occupational therapy. “I have seen great progress in flexibility and balance resulting in increased functional tasks, like reaching for cabinets to pick up bottles, books and magazines; opening refrigerator doors; turning faucets; and picking out clothes from the closet, just to name a few,” she says. “I was moved when my stroke patient told me one day that she was able to hug her husband, something she had not done for more than a year.”

OTs in home health settings also are becoming trained in LSVT Big. “It’s still too early to track outcomes, but we anticipate with this approach to see a reduction in falls and improvement in activities of daily living,” says Mark Heitchu, MPT, therapy director at Residential Home Health in Madison Heights, Mich.

The home health agency, which serves a clientele of 2,000, has trained nearly 100 of its home health therapists in LSVT Big for patients with Parkinson’s, multiple sclerosis and strokes, as well as other movement issues, says Bernadette Kosir, OTR/L, program manager at Residential Home Health.

“It’s part of our culture now,” Kosir says. “We use it for all kinds of diagnoses, not just neurological — almost anyone with a gait or balance issue. It’s part of our fall risk reduction program and our balance training and safety.”

Study Results

While in her doctoral program at Arizona, Farley learned about LSVT Loud from her classmate, Cynthia Fox, PhD, CCC-SLP, research associate at the University of Colorado-Boulder and co-founder and chief clinical officer of LSVT Global (LSVTGlobal.com), which offers training and certification in these proprietary techniques.

“I told her we should apply those principles to PT,” says Farley, who went on to develop the exercises and name her program LSVT Big.

Farley has since completed two studies on the therapy, including a randomized clinical trial funded by the National Institutes of Health to document the efficacy of an exercise approach that targets the Parkinson’s symptoms of slow/small movements (bradykinesia/hypokinesia) using LSVT Big. The results will be published sometime this year, Farley says.

“We compared Big to an outpatient control intervention,” she says. “Both groups improved with intensity, but Big had more improvement in trunk rotation and stride length.” The therapy also can have positive outcomes on speed, balance and quality of life, she adds.

The next step in the therapy, an integrated treatment program that simultaneously targets speech and limb motor disorders in people with Parkinson’s, recently has been developed by LSVT Global, Farley says. Results from pilot work revealed all pilot subjects with Parkinson’s increased vocal loudness and improved gait. This program is undergoing further development and testing. Ÿ

Teresa McUsic is a contributing writer for Today in OT.