A commonly chosen option for physical therapy in Parkinson’s disease (PD) is Lee Silverman BIG and LOUD, offered at several centers around the state. This program, like much of physical therapy, takes into account that one of the major issues underpinning the problems with PD results from dysfunction of the part of the brain called the basal ganglia. An important role of the basal ganglia is to serve as a sort of quality control center for the brain, checking movement and speech to make sure each is being carried out properly. However, in PD, the basal ganglia often reports that things are fine when they are not. This misinformation is why sometimes patients are unaware of the abnormal movements or speech patterns. Thus, one of the big goals of physical therapy is to make the patient aware of what they are doing wrong. Following this, the person is taught a new way to perform an old activity such as speaking or walking. Repetition is key so that the new way of doing something is reinforced. In doing this, the brain uses synaptic plasticity to form a new pathway. Those new connections lead to new ways of doing things, and essentially bypass the bad circuits.
Lee Silverman Voice Treatment, now known as LSVT LOUD is a speech treatment specifically designed for patients with PD, and is named after Lee Silverman, a PD patient who was treated in the 1980s. Since the 80s, there have been multiple studies showing at least short term benefit with LSVT, and patients have found the treatment very helpful for volume of speech, intonation, articulation, and facial expression (1). The basic gestalt is to first help people with PD recognize that the voice is too soft. Following this, one strengthens muscles of speech through a series of progressive exercises in four 60-minute sessions per week for one month. This motor learning stimulates the brain to form new pathways (2). People with PD learn that the louder voice is normal, and eventually will feel normal about the new speech pattern (3). LSVT LOUD has been successfully taught to people in all stages of PD, and is usually most effective in early or middle stages of PD.
In the last few years the same approach has been used to develop improvements in limb movement and gait with a program known as LSVT BIG (4). Training tends to focus on increased amplitude of limb and body movement. Studies have shown improvements in movement, speed, balance, and quality of life. LSVT BIG can be delivered by a physical or occupational therapist certified in this treatment, and is also taught to patients in four 60-minute sessions per week for a month. Usually BIG and LOUD are done on the same day. The exercises are built upon in a repetitive pattern meant to improve the movements used in activities of daily living, again forming new connections in the brain.
I have many times seen patients benefit from these strategies. Sandi Merrill, a person with PD, notes LSVT BIG and LOUD has been “very beneficial and I have more freedom of movement. It’s improving my health.” She says when talking with others, “they notice a change.” Her husband George notes “several people have commented how much easier it is to have a conversation with her. And, BIG is helping her with everyday things she used to find difficult and frustrating, like getting out of a chair in a restaurant.”
I had the chance to discuss LSVT with Tina Phillips, PT at Mid Coast Hospital in Brunswick. She tells me that within her group there are four clinicians certified in BIG and two certified in LOUD, all busy treating patients. Tina notes “people seem to really enjoy the program and get a kick out of learning to train their brain.” She tells me that LSVT is most effective for people who are very motivated. If they do the exercises they make improvements, get excited, and feel a lot of encouragement. She emphasized to me that carrying on exercise after the class is very important to have a continued benefit. Some patients keep this up very well at home and some do not. Fortunately, this May on Thursdays from 11 a.m. to noon there will be a new graduate LSVT program at the Landing YMCA in Brunswick. The program will incorporate all four Mid Coast BIG instructors, who will go through exercises with graduates from any LSVT program. There will also be new activities including Argentine tango dancing, yoga, and Tai Chi. Tina will be there May 19th. The Landing YMCA is located in the old Naval Air Station, 24 Venture Avenue, Brunswick, ME, 207-844-2801.
-Bill Stamey, M.D.
1. Journal of the International Neuropsychological Society, 2014;20(3):302-12.
