1

The LSVT Big Program, Accompanied by Balance Training and Therapeutic Exercise as

Treatment for Parkinson’s Disease: A Case Report

By: Cody Gunselman, SPT

Cleveland State University

2

Abstract:

Background and Purpose: As many as one million Americans live with Parkinson’s

Disease. Approximately 60,000 Americans are diagnosed with Parkinson’s each year, with many

cases going undetected. Physical therapy, along with pharmaceutical intervention, can be helpful

in delaying the effects of Parkinson’s Disease (PD). The purpose of this case report is to

demonstrate the effectiveness of using the LSVT program, accompanied by therapeutic exercise

and balance training to manage the effects of Parkinson’s Disease. Case Description: A 77 -

year old Caucasian female, with MRI confirmation of Vascular PD. Her chief complaints

included numbness in her feet, decreased stamina for walking, feelings of unsteadiness with

walking, and stiffness throughout her spine. Impairments included decreased cervical active

range of motion (AROM), impaired posture, impaired balance, decreased gait speed, and

unsteady gait. The patient was seen for fourteen visits, with visits focusing on instruction and

completion of the LSVT BIG program, along with balance training and improvements in gait.

Outcomes: Upon re-evaluation, the patient had decreased her Timed Up and Go (TUG) time,

increased Activities Specific Balance Confidence Scale Score, improved balance, demonstrated

improved gait, and completed assessments without the use of a wheeled walker. Discussion:

This case report helps to provide current insight into using the LSVT BIG program to treat

impairments of PD, supplemented by balance training and therapeutic exercise. The results

illustrate the effectiveness of using the LSVT BIG protocol as the primary method of treatment

for Parkinson’s related impairments, while also displaying the importance of using additional

interventions.

Words: 250

3

Background and Purpose:

More than 10 million people worldwide are living with PD.1 Incidence of PD increases

with age, with projections displaying that the incidence of Parkinson’s could double by the year

2030. Approximately 3% of people diagnosed with Parkinson’s are diagnosed with Vascular

Parkinsonism. Medication costs for an individual person with PD average $2,500 a year, with

surgery costing up to $100,000 dollars per patient.1 The physiology of Parkinson’s is a loss of

dopaminergic neurons in the pars compacta region of the substantia nigra. Symptoms are often

not seen until around 60–80% of dopaminergic neurons have degenerated.2 Pharmaceutical

management is oriented towards managing the symptoms of PD. Intensive, early rehabilitation

through exercise can delay the need for increasing drug treatment.3

The last two decades have seen a dramatic increase in the clinical interest in using

exercise as a treatment for mobility problems in people with PD. Symptoms of PD include both

motor and non-motor aspects. Motor symptoms consist of tremors, rigidity, bradykinesia, and

postural instability including gait and balance disturbance.4 Specifically, patients exhibit

impaired coordination, under-scaling, difficulties with sequential complicated and simultaneous

movements, and difficulty transitioning between movements. With exciting advances in basic

science research suggesting neurochemical and neuroplastic changes after exercise, an increasing

number of studies are documenting features of mobility improvement. Exercise has the potential

to help both motor (gait, balance, strength) and nonmotor (depression, apathy, fatigue,

constipation) aspects of PD as well as secondary complications of immobility (cardiovascular,

osteoporosis). 5

Pharmaceutical intervention to control symptoms is usually required. In certain cases,

surgical intervention such as deep brain stimulation can be utilized. The recently developed

4

LSVT BIG program, aims to treat impairments of PD by restoring normal movement amplitude

by recalibrating the patient’s perception of movement execution.6 The treatment focuses on

intensive exercising of large amplitude movements. The high intensity of LSVT BIG is

predefined by a training mode of 16 individual 1-hour sessions for 4 weeks and an independent

home program. Every exercise is repeated at least 8 times and performed with an effort of 80%

of maximal workload. The goal is to teach participants to carry over and sustain bigger

movements in their daily activities.7

LSVT BIG has been effective in improving mobility for people with PD in a variety of

stages of the disease. The effect is achieved by targeting damaged basal ganglia through

repetitive activation across motor regions in the brain that are involved in normal amplitude

movements. An effort scale helps participants learn to calibrate their movements to overcome the

sensory mismatch between perceived movement and the actual completed movement. The LSVT

BIG approach is unique in incorporating shaping techniques through use of therapist modeling or

tactile/visual cues, improving self-perception, and leading to improvement in movement

patterns.7

Several studies demonstrate that the LSVT BIG program has proven to be effective in

improving gait, balance, bed mobility, and posture. Clinical research has investigated the effects

of the BIG protocol on outcome measures including the TUG, Functional Reach Test (FRT), gait

speed, the Berg Balance Scale (BBS), the Lindop Parkinson’s Disease Mobility Assessment

(LPA), and the Unified Parkinson’s Disease Rating Scale (UPDRS).6,7 Challenging and

progressive balance training programs for patients with PD have been shown to demonstrate

improvements in the Mini Balance Evaluation Systems Test (MBEST).8 Balance training with

rhythmical cues to promote attention, self-perception, speed, and range of motion have been

5

found to improve scores in outcome measures such as the MBEST, the TUG, and the BBS.9

There is limited research available which discusses the results of using other intervention

strategies in conjunction with the LSVT BIG program, specifically, interventions related to

balance training and gait training.

The HOAC II10 model was used to guide the framework of this case report because it

suggests a progression for directing patient management. This model fueled the clinical decision-

making process for treating this patient. The purpose of this case report is to demonstrate the

effectiveness of using a multimodal approach of therapeutic exercise and balance training in

conjunction with the LSVT BIG program to treat the impairments of PD in a 77-year old patient.

Words – 676

Case Description: Patient History and Systems Review

A 77 - year old, Caucasian female, was referred by her primary care physician to

outpatient physical therapy for evaluation and treatment of PD. Her chief complaints included

numbness in her feet, decreased stamina for walking, feelings of unsteadiness with walking, and

stiffness throughout her spine. She was officially diagnosed with Vascular PD two to three years

ago via MRI. She takes Carbidopa – Levodopa two times daily by mouth, with her first dose

coming around 9 am and the second dose around 1 pm. She reports that she often forgets about

taking the 3rd dose, which is supposed to be at 5 pm. The medication was prescribed to control

the intentional tremor through her left hand. The patient denies any freezing associated with her

PD. Other pertinent medical history included throat cancer three years ago for which she

received radiation therapy, high blood pressure, four cysts in her iris, and bilateral lower

extremity (LE) edema.

6

The patient reported that she has been using a wheeled walker (WW) for approximately

five years to ambulate safely in public. She does not use the WW at home, however she tends to

“furniture walk.” The patient has attempted to use a cane in the past, however she does not feel

that the cane provides her with enough stability for walking. She was doing little exercise at

home. Other difficult activities include turning and trouble keeping balance if someone were to

bump into her in public.

The patient lives at home with her husband, in an apartment equipped with several

assistive devices. She has grab bars in the bathroom, including near the toilet and the shower.

She also uses a shower chair to assist with bathing. She is independent with all activities of daily

living (ADLs). The patient’s goals were to feel more confident with her movement and to attend

exercise classes again.

Words: 308

Clinical Impression #1

The patient’s primary problems were impaired posture, impaired balance, and unsteady

gait. She also had decreased cervical active range of motion (AROM), decreased gait speed, and

numbness in her feet. MRI results had confirmed she has Vascular PD, which explained the

numbness in her feet. It was important to gain an understanding of the patient’s past

rehabilitation with her PD. It was found throughout the subjective history that the patient

previously attended “Delay the Disease” exercises classes on a regular basis.

An examination strategy was developed based upon the HOAC II model10 that considered

the patient’s impairments, past medical history, and data collected through screening and intake

forms. The patient complained of difficulty with decreased stamina while walking and expressed

7

lack of confidence maintaining balance, especially when out in public, so it was imperative to

perform thorough balance testing in order determine what portions of balance the patient was

having difficulty with. This could be done using outcome measures such as the TUG, which

involves speed and turning components. Also, pieces of the Tinetti Performance Oriented

Mobility Assessment (TPMA) and BBS can be used to gain a better understanding of more

specific balance activities the patient may be having difficulty with.

In addition to balance impairments, there are many other common deficits of PD. One

possible impairment includes flexed posture; therefore, it was crucial to complete a thorough

postural examination in both sitting and standing. Patients with PD are also likely to have

decreased ROM, specifically in the cervical spine and trunk, so it was important to observe

AROM. Another common symptom is bradykinesia, thus coordination testing of both the upper

and lower extremities was necessary. Due to likely postural and balance impairments, it was

important to review if the patient is having any difficulty with functional tasks, including

transfers. The patient was a good subject for this case report because she was an excellent

candidate for the LSVT Big Program based off her trunk rigidity, range of motion deficits, and

balance disturbance. Also, her PD was not too far advanced in the sense that her impairments

could not be treated. She was motivated to participate physical therapy and the LSVT Big

Program.

Words: 363

Examination:

8

Physical examination began with a postural analysis as described by Magee.11 The patient

demonstrated forward head posture with rounded shoulders, thoracokyphosis, and decreased

lumbar lordosis.

Cervical AROM was assessed by observation.12 The patient was significantly restricted

with cervical AROM. She had approximately 75% limitations in all directions, however, she had

no pain with any cervical motion. Upper extremity (UE) and LE AROM was observed and

assessed with the patient in various positions, including sitting, supine, and side-lying.12

Coordination testing was administered to both the upper and LE. Coordination testing

was conducted using those procedures outlined by Schmitz and O’Sullivan.13 The patient

exhibited slight bradykinesia with rapid alternating movements, oppositional movements were

intact, finger to nose and heel to shin tests were also intact. The patient’s sensation was intact to

light touch, noting numbness and tingling throughout the entirety of both of her feet.

Manual muscle testing (MMT) of the patient’s lower extremities showed that the

patient’s strength was grossly 4+/5 on both sides. Muscle testing was completed with the patient

in both sitting and side-lying. The patient did not feel comfortable getting into a prone position to

MMT for hip extension. These positions and procedures for MMT are defined by Reese.14

The patient’s balance was assessed using components of the TPMA and the BBS,

developed by Tinetti and Berg respectively.15,16 Both outcome measures have normative

reference values for patients with PD. The Five Times Sit to Stand Test was administered, as

well as the TUG. These assessments were followed by procedures outlined by Lambert and

Gallagher.17,18

9

Figure 1. Displays results of balance assessments used during the examination process,

including those taken from both the Berg and Tinetti outcome measures, as well as the Five

Times Sit to Stand Test and the TUG. Blue bars represent the patient’s time in seconds.

Time in seconds is represented on the Y – Axis.

It is important to note, that although the patient could perform the narrow base of support

stance with eyes open (NBOS) for greater than thirty seconds, the patient had excessive postural

sway throughout the test. The patient was unable to perform tandem stance and NBOS stance

with her eyes closed. The patient performed the Five Times Sit to Stand Test without UE support

and with standby assistance (SBA) from the therapist. Since the patient had noted having

difficulty with turning, the therapist tested her ability to turn 360 degrees. The patient’s turning

was discontinuous, with short shuffling steps. She had no loss of balance with turning.

Perturbations were also assessed; however, the patient was unable to maintain balance during

this test.15,16

The patient’s gait was assessed by having the patient ambulate in the gym area. The

patient was asked to ambulate using her WW. She exhibited flexed posture, with a widened base

10

of support and decreased foot clearance. She demonstrated decreased heel progression, shuffling

steps, and decreased gait speed. The patient then attempted to walk without her wheeled walker,

resulting in further decreased gait speed. She had diminished bilateral arm swing, a narrowed

base of support, and increased hesitation with turning. The gait assessment was completed using

those procedures outlined by Magee.11

Prior to examination, the patient was asked to complete a written outcome measure titled,

“The Activities Specific Balance Confidence Scale (ABC).” This form allowed the patient to rate

her confidence performing certain tasks with a percentage score up to 100%. The patient

possessed only 55% self-confidence in her balance. The patient was asked by the therapist during

the examination, to give a percentage rating of what she perceived her level of function to be.

The patient stated that she felt she was functioning at “around 50%” of what she could be.

Exam Procedure/Outcome Measure

Reliability Validity

MMT Intra-rater = .8 to .99 .95Tinetti Interrater = .84 Criterion = -.45BBS Interrater = .95 Criterion = -.64

5x sit to stand Interrater = .99 Criterion = .58TUG Interrater = .99 Criterion = .66

ABC scale Test – retest = .96 Criterion = .66Figure 2. Reliability and Validity Chart14,15,16,17,18

Words: 559

Clinical Impression #2

The patient’s symptoms were consistent with impairments associated with PD. The

patient possessed deficits in posture and postural control, balance, AROM, gait, and decreased

confidence in her balance. The patient demonstrated bradykinesia and postural rigidity. Evidence

has shown that patients with PD who are treated early and conservatively with physical therapy

11

can experience positive outcomes, as well as delay the disease process.3, 5 Based on the expertise

of the clinical instructor and experience of the student physical therapist (SPT), it was decided

that the patient was a good candidate to be included in the LSVT BIG Program and to proceed

with physical therapy intervention. The patient will perform a modified version of the BIG

program, where she will be coming in for appointments two to three times per week. A home

program will be crucial to this patient’s success since she will not be coming in the full four

times per week as outlined by the BIG program. The patient was understanding that compliance

with a home physical therapy program will be vital to her success given that she is not coming in

as often.

A multi-faceted approach was determined to be the most appropriate method of

treatment, with the focus being the performance of the LSVT BIG program. However, the

clinical instructor also felt it was important to supplement the BIG program, with various balance

exercises, gait training, and therapeutic exercise. These components of the patient’s plan of care

would be performed both in the clinic, as well as part of the home exercise program.

Reassessment of the patient was to take place after ten therapy visits to determine the

effects of physical therapy treatment. It would be decided after ten therapy visits if the patient

would continue to benefit from further therapy, or if she would be discharged to continue with

her home program. The patient would also complete the ABC scale again to ensure the patient

had perceived more self-confidence in her overall balance.

Words: 327

Intervention:

12

The patient was seen for 14 visits over approximately one and a half months. This is

modified from the prescribed protocol of the LSVT BIG program, which states that the patient

must be seen four times per week for one month for a total of 16 visits.20 This patient scheduled

appointments two to three times per week, at the request of the patient.

Initially, the patient completed adapted versions of the BIG exercises due to safety

concerns secondary to balance impairments and decreased patient confidence. The adapted

version of the program allowed the patient to use one UE support when performing the standing

exercises.21 The patient progressed to performing the BIG protocol without using any UE

support. Throughout the first few sessions of performing the BIG exercises, the patient required

contact guard assist (CGA) from the therapist with a gait a belt. (SBA). Early in the episode of

care (EOC), she required significant amounts of verbal and manual cueing for improved posture

and proper technique with the BIG exercises. The therapist and student physical therapist

performed the exercises with the patient, providing a visual cue of proper movements. Near the

end of the EOC, the patient could perform the program largely without verbal and manual

correction. The patient performed eight repetitions of exercises with increased intensity,

requiring frequent rest breaks in between repetition.

The LSVT BIG protocol served as the primary intervention for the patient, with

therapeutic exercise, balance, and gait training serving as co-interventions. Therapeutic exercises

included postural exercises such as posterior shoulder rolls, cervical AROM in all directions, and

lower trunk rotations. During treatment sessions, the patient performed other exercises such as

side stepping, anterior/posterior step-overs using hurdles, and alternating toe taps on a 6-inch

step. Gait training typically consisted of ambulation around the indoor track area (160 ft. is one

lap). Changing directions was incorporated by having the patient ambulate approximately 50 feet

13

and focusing on taking increased step length during turning. The patient required frequent verbal

cueing to correct for improved posture, increased step length, and to incorporate bilateral arm

swing.

The patient was provided an extensive home program as a supplement to physical therapy

sessions. After the evaluation, the patient was prescribed postural exercises and low difficulty

balance exercises to begin working on at home. Once the patient started the LSVT BIG program,

she began performing the adapted version of these exercises at home on the days she was not

coming into the clinic for therapy.

Interventions

Warm up – 5 minutes on Nu Step, resistance set at Level 5.

Gait Training – approximately 2-3 laps around track (160 ft.), also incorporated turning

LSVT BIG exercises (8 repetitions of each)

Balance training

Figure 3. Outlines the design of a typical 60 - minute therapy session.

Examples of Balance Progressions

Progression timeline – typically when the patient could perform a balance exercise for 20-30 seconds, the difficulty of the exercise was increased

Different stances – regular double limb stance, modified tandem stance, tandem stance, narrow

base of support stance

Eyes open and closed

Changing surfaces – rocker board, foam pad

Head turns (rotation side to side, looking up and back to neutral)

Figure 4. Describes balance training progressions throughout the plan of care.

14

Adapted LSVT BIG Maximal Exercises Standard LSVT BIG Maximal Exercises

Floor to Ceiling

Starting position – sit at edge of chair with big posture1. Reach out BIG2. Reach down BIG3. Reach up BIG4. Reach back BIG5. Hold 10 counts. Keep posture BIG6. End BIG with hands on thighs

Floor to Ceiling

Starting position – sit at edge of chair with big posture1. Reach out BIG2. Reach down BIG3. Reach up BIG4. Reach back BIG5. Hold 10 counts. Keep posture BIG6. End BIG with hands on thighs

Side to Side

Starting position – sit at the edge of a chair with BIG posture. Start with your arm out with a BIG hand. Place the other hand on the chair besides you. 1. Reach Across your body with a BIG reach and BIG push with your leg. Maintain BIG posture. 2. Hold 10 counts. Keep posture BIG. 3. End BIG with your hand on your thigh.

Side to Side

Starting position – sit at the edge of a chair with BIG posture. Start with your arm out to the side with a BIG hand. 1. Reach Across your body with a BIG reach and BIG push with your leg. Maintain BIG posture. 2. Hold 10 counts. Keep posture BIG. 3. End BIG with your hand on your thigh.

Forward Step and Reach

Starting position – stand with BIG posture. Hang onto stable object for support. 1. Step forward with one foot and land BIG. Open your arm and hand BIG. 2. Return the same foot back to starting position with a BIG stomp and BIG slap of the hand.

Forward Step and Reach

Starting position – stand with BIG posture. 1. Step forward with one foot and land BIG. Open your arms and hands BIG. 2. Return the same foot back to starting position with a BIG stomp and BIG slap of the hands.

Sideways Step and Reach

Starting position – Stand with BIG posture. Hang onto a stable surface with one hand. 1. Step out to the side with the one foot and land BIG. Reach out with a BIG arm and BIG hand. 2. Return the same foot back to the starting position with a BIG stomp and BIG slap of the hand.

Sideway Step and Reach

Starting position – stand with BIG posture.

1. Step out to the side with the one foot and land BIG. Reach out with BIG arms and BIG hands. 2. Return the same foot back to the starting position with a BIG stomp and BIG slap of the hands.

Backwards Step and Reach

Starting position – stand with BIG posture and with a BIG hand in front of you. Hold onto a stable support with the other hand. 1. Step back BIG with the one foot while reaching back with a BIG arm. 2. Return the same foot back to starting position with a BIG stomp and BIG arm in front.

Backwards Step and Reach

Starting position – stand with BIG posture and with BIG hands in front of you. 1. Step back BIG with the one foot while reaching back with BIG arms. 2. Return the same foot back to starting position with a BIG stomp and BIG arms in front.

15

Forward Rock and Reach

Starting position – place one foot forward/one foot back in a wide stance with BIG posture. Hang onto a stable surface for support with one hand. 1. Begin rocking forward and backward from one foot to the other. No stepping. 2. Gradually add a BIG arm swing and keep rocking forward and back. Keep your posture BIG.

Forward Rock and Reach

Starting position – place one foot forward/one foot back in a wide stance with BIG posture. 1. Begin rocking forward and backward from one foot to the other. No stepping. 2. Gradually add BIG reaches and keep rocking forward and back. Keep your posture BIG.

Sideways Rock and Reach

Starting position – Stand with a BIG base of support and BIG posture. Hang onto a stable surface behind you with one hand. 1. Twist BIG to one side as far as possible while reaching across your body with a BIG reach2. Return to starting position with a BIG slap of your hand and BIG posture.

Sideways Rock and Reach

Starting position – Stand with a BIG base of support and BIG posture. 1. Twist BIG to one side as far as possible while reaching across your body with a BIG reach. Open your arms as BIG as you can. 2. Return to starting position with a BIG slap of your hands and BIG posture.

Sit to Stand

Starting position – Sit at the edge of the chair with BIG posture. 1. Reach forward with a BIG reach and BIG effort so that your hips lift off the chair. 2. Open your arms BIG as you stand up with BIG posture. 3. Reach forward with a BIG reach and sit down with good control.

Sit to Stand

Starting position – Sit at the edge of the chair with BIG posture.1. Reach forward with a BIG reach and BIG effort so that your hips lift off the chair.2. Open your arms BIG as you stand up with BIG posture.3. Reach forward with a BIG reach and sit down with good control.

Figure 5. The table is a description of the Adapted and Standard LSVT BIG Maximal

Exercises as given to the patient. The patient completed 8 repetitions of each exercise with

each UE/LE. The Standard LSVT BIG Maximal Exercises were used as progressions to the

adapted exercises when the patient’s balance and confidence had improved. The Standard

Exercises incorporated both UE, while taking away UE support.21

Words: 411

Outcomes:

After 10 treatment sessions, the patient reported an increase in functional level, improved

ambulation without using her WW, more confidence with turning, and felt ready to begin

16

attending “Delay the Disease” classes. She reported avoiding “furniture walking” at home. She

noticed decreased stiffness and improved cervical AROM. The patient was independent with

completing the LSVT BIG exercises, however she continued to benefit from verbal cueing for

increased quality of the movements.

Reassessment of gait showed improved confidence, increased heel/toe progression,

improved gait speed, better turning quality, increased step length, and improved bilateral arm

swing. The patient felt comfortable enough to ambulate without her WW in the gym area.

The patient’s perceived functional level improved to 70%, a 20% increase. The ABC

scale was re-administered, with the patient increasing from being 55% confident to 66%

confident. The patient improved her TUG scores, quality of movement with the 5x Sit to Stand

test, and improved scores with balance assessments from the TPMA and BBS. She could

maintain balance through light perturbations and could perform 360 degree turning continuously,

with less hesitation and no shuffling steps.

The patient made excellent progress since beginning therapy and met or partially met

most of her goals. The therapist and patient agreed that the patient should continue therapy for

four more sessions to strive towards completing the LSVT BIG exercises without UE support

while maintaining quality movement patterns. The SPT reassessed tandem, NBOS, and single

leg stance balance testing, noting patient improvements from the previous re-evaluation with

each assessment.

17

5x Sit to Stand TUG R Tandem Stance

L Tandem Stance

R Single Leg Stance

L Single Leg Stance

02468

1012141618

Final Balance and Outcome Measure Assessments

Initial Final

Balance Assessment/Outcome Measure

Tim

e (S

econ

ds)

Figure 6. The chart displays results of outcome measures at initial evaluation and at

discharge.

NBOS with eyes open and eyes closed are not displayed because the patient could

maintain balance for greater than 60 seconds with these tests. Right single leg stance and left

single leg stance were not assessed at initial evaluation, however the patient could complete

these assessments at discharge. Although Five Times Sit to Stand time did not improve, the

patient’s quality of movement was better. The TUG assessment at initial evaluation was

completed with a WW, however at discharge the patient completed the TUG without use of a

WW.

Words: 341

Discussion:

Although PD is a degenerative disease, inactivity may accelerate the progression of

symptoms.22 Recent reviews and research suggest that exercise is important in the early stages of

PD, having positive effects on both motor and non-motor symptoms of PD.5, 23 Exercise is an

18

established therapeutic adjunctive in Parkinson’s disease (PD) but little is known about dose–

response relationships of exercise in patients with PD.24 LSVT-BIG focuses on high-amplitude

movements which are trained with multiple repetitions, high-intensity and increasing

complexity.24 LSVT BIG training has been compared to other physical therapy interventions

such as Nordic walking and general therapeutic exercises, with the LSVT BIG protocol

demonstrating the biggest improvements in the motor score of the UPDRS, the 10 meter walk

test, and the TUG.25 However, there is little research suggesting using supplemental interventions

to the LSVT BIG program.

The purpose of this case report was to illustrate successful PT management of a patient

with Vascular PD with the primary intervention on using the LSVT BIG treatment protocol, with

therapeutic exercise, gait training, and balance training serving as co-interventions. Past studies

have supported the use of the LSVT BIG program, but few have examined altering the time

frame prescription of the protocol and using the adapted form of the exercises, while

supplementing the program with other physical therapy interventions.

Intensity of training has been postulated to be crucial for success of LSVT BIG, but the

standard protocol comprising of 16 individual 1-hour therapy sessions is not feasible for most

patients.6 It was important in this case study to demonstrate that the patient could still have

excellent progress while lowering the frequency of face-to-face treatments. Due to decreased

weekly sessions, the patient was required to be adherent to a strict home exercise program.

While the LSVT BIG exercises were utilized at every treatment session, balance and gait

training played an important role in the patient’s progress as well. The LSVT BIG program aims

to treat PD by restoring normal movement amplitude by recalibrating the patient’s perception of

movement execution.7 Once patients can increase the amplitude of their movements, they can

19

transfer these movement patterns to skills such as gait and transfers. It is fair to hypothesize that

the patient’s improvements in gait and balance were largely because of the BIG exercises,

however gait and balance training were vital in honing the big amplitude movements the patient

had learned through the BIG program.8 Verbal cueing during gait training helped the patient

maintain continued attention to her movement execution until it became more automatic.

Few studies have incorporated using a modified and adapted version of the LSVT BIG

program, with therapeutic exercise, balance exercises, and gait training serving as co-

interventions. This case report helps to give current insight into using other interventions to

supplement the LSVT BIG program, while also demonstrating that the BIG program dosage can

be modified and still have positive effects in recalibrating patient’s movements in order to

improve gait, balance, and function. Further research into the use of a modified LSVT BIG

program with supplemental interventions may be warranted due to the current lack of evidence

available.

Words: 515

Total Words in Body of Manuscript: 3500

20

References

1. Statistics on Parkinson's. Parkinson's Disease Foundation Web site. http://www.pdf.org/parkinson_statistics. Updated 2017. Accessed 05/09, 2017.

2. Chambers DJ, Sebastian J, Ahearn DJ. Parkinson's disease. BJA Education. 2017;17(4):145-149.

3. Rozita, G. (1,2), Maestri R(3), Bertotti G(3), et al. Intensive rehabilitation treatment in early parkinson's disease: A randomized pilot study with a 2-year follow-up. Neurorehabil Neural Repair. 2015;29(2):123-131.

4. Chan A. Parkinson specific physical therapy. 2016.

5. van dK, King LA. Effects of exercise on mobility in people with parkinson's disease. MOVEMENT DISORDERS. 2013;28(11):1587-1596.

6. Janssens J, Malfroid K, Nyffeler T, Bohlhalter S, Vanbellingen T. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with parkinson disease: A case series. Phys Ther. 2014;94(7):1014-1023.

7. Millage B, Vesey E, Finkelstein M, Anheluk M. Effect on gait speed, balance, motor symptom rating, and quality of life in those with stage I Parkinson’s disease utilizing LSVT BIG®. Rehabilitation Research & Practice. 2017:1-8.

8. Leavy B, Kwak L, Hagströmer M, Franzén E. Evaluation and implementation of highly challenging balance training in clinical practice for people with Parkinson's disease: protocol for the HiBalance effectiveness-implementation trial. BMC Neurology [serial online]. February 7, 2017;17:1-9. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 30, 2017.

9. da Costa Capato T, Tornai J, Ávila P, Barbosa E, Piemonte M. Randomized controlled trial protocol: Balance training with rhythmical cues to improve and maintain balance control in Parkinson’s disease. BMC Neurology [serial online]. September 7, 2015;15Available from: PsycINFO, Ipswich, MA. Accessed May 30, 2017.

10. Riddle D, Stratford P. Is this change real? Interpreting patient outcomes in physical therapy. First edition. Philadelphia: FA Davis Company; 2013

11. Magee D. Orthopedic physical assessment. 6th ed. Elsevier; 2014.

12. Berryman Reese N, Bandy W. Joint range of motion and muscle length testing. 2nd ed. Saunders; 2009.

13. O'Sullivan S, Schmitz T. Physical rehabilitation. 6th ed. F.A Davis; 2014:1536.

14. Berryman Reese N. Muscle and sensory testing. 3rd ed. Elsevier; 2013:616.

15. Tinetti performance oriented mobility assessment. Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1039. Published 2010. Updated 2014. Accessed 05/29, 2017.

21

16. Berg balance scale. Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=888. Published 2010. Updated 2013. Accessed 05/29, 2017.

17. Five times sit to stand test. Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1015. Updated 2013. Accessed 05/29, 2017.

18. Timed up and go dual task; timed up and go (cognitive); timed up and go (motor); timed up and go (manual). Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1057. Updated 2014. Accessed 05/29, 2017.

19. Activities specific balance confidence scale. Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=949. Updated 2013. Accessed 05/30, 2017.

20. Ueno T, Sasaki M, Tomiyama M, et al. LSVT-BIG Improves UPDRS III Scores at 4 Weeks in Parkinson’s Disease Patients with Wearing Off: A Prospective, Open-Label Study. Parkinson's Disease (20420080) [serial online]. February 2017;:1-4. Available from: Academic Search Complete, Ipswich, MA. Accessed June 4, 2017.

21. Adapted LSVT BIG maximal daily exercises. http://www.lsvtglobal.com/images/uploads/digital_files/26067/adapted_lsvt_big_exercises_2015.pdf. Updated 2015. Accessed 06/04, 2017.

22. CACIULA n, HORVAT M, NOCERA J. EXERCISE FREQUENCY AND PHYSICAL FUNCTION IN PARKINSON'S DISEASE. Bulletin Of The Transilvania University Of Brasov, Series IX: Sciences Of Human Kinetics [serial online]. July 2016;9(2):27-34. Available from: Academic Search Complete, Ipswich, MA. Accessed June 10, 2017.

23. Murray D, Sacheli M, Eng J, Stoessl A. The effects of exercise on cognition in Parkinson’s disease: a systematic review. Translational Neurodegeneration [serial online]. 2014;(1):5. Available from: OaFindr, Ipswich, MA. Accessed June 10, 2017.

24. Ebersbach G, Grust U, Ebersbach A, Gandor F, Wegner B, Kühn A. Amplitude-oriented exercise in Parkinson’s disease: a randomized study comparing LSVT-BIG and a short training protocol. Journal Of Neural Transmission [serial online]. January 1, 2014;122(2):253-256. Available from: Scopus®, Ipswich, MA. Accessed June 10, 2017.

25. Ebersbach G, Ebersbach A, Wissel J, et al. Comparing Exercise in Parkinson's Disease-The Berlin LSVT (R) BIG Study. Movement Disorders [serial online]. n.d.;25(12):1902-1908. Available from: Science Citation Index, Ipswich, MA. Accessed June 10, 2017.

22

23