5 “BIG” Things We Learned About Treating Patients with Parkinson’s

As three of the faculty for the LSVT BIG Training and Certification Course, we have had the incredible opportunity to learn from each other over the years. Although each of us has unique backgrounds and paths that led us to become Occupational Therapists, we share a common passion for helping people with Parkinson's disease (PD).

We have also realized there are common themes in the lessons we have each learned and in ways we have changed our approach to treating patients with PD since becoming LSVT BIG Certified.

1. Never underestimate your patient’s potential

When you evaluate a person who has had PD for a long time, one of the first things you might notice is a flat affect, followed by a bit (or a lot) of difficulty in getting up from a chair, a slow, shuffling gait and flexed posture. It would be easy to make a quick judgment about that patient’s potential (or their desire to even be in therapy!), but time and time again, we are surprised at what can be magically unlocked with therapy.

“I remember a gentleman who arrived for his first OT appointment with a less than enthusiastic facial expression” says Erica. “He was walking very slowly with a quad cane and had a propulsive, shuffling gait pattern. After evaluating him, it was apparent to me that he was able to move bigger and better when cued, so I knew he’d be a good candidate for LSVT BIG."

Over the course of the of intensive LSVT BIG treatment, four times a week for four weeks, his attention to amplitude greatly improved his safety with functional mobility to the point where was able to walk again with complete confidence and without a cane. I was shocked not only by his potential to improve his mobility, but also by the profound effects it had on his mood and facial expression. I realized that I had initially misjudged his ability and motivation based upon his facial masking, but was glad I decided to give him the benefit of the doubt!”

2. Don’t be afraid to push your patient

This really goes along with the first point. Your patients with PD have great potential, but the only way to fully realize that potential is by not being afraid to “push them." You are likely familiar with key principles which can help to drive neuroplasticity and motor learning from your neuro coursework or from reading current literature. Exercising intensively is one key principle which has been found to be very important in people with PD. Even though we might know these principles in our heads, applying them in real world practice is often a challenge!

Before taking the LSVT BIG Training and Certification Course, the three of us agreed that it would have taken us out of our comfort zones to really push a patient who appears to be somewhat frail due to the symptoms of moderate to advanced PD. Now we understand not only the untapped potential they have, but how necessary it is to provide treatment that is sufficiently intensive and includes a high amount of practice to make lasting gains. And - just like the research shows - it really does work!

On the other end of the spectrum are those patients who are so high functioning, that prior to LSVT BIG, we may have simply provided instruction in a home exercise program and discharged them. Why? Unless you know how to “unmask” the deficits, it is not always easy to see how those subtle symptoms can impact our patients’ occupational performance both now and in the future. Furthermore, we did not appreciate the severity of the underlying neuropathology that begs us to use intensive exercise to potentially slow symptom progression and delay disability.

A patient one of us has been working with for many years has a very successful business in landscaping. At first, he had some doubts how LSVT BIG would help him because he was experiencing very few difficulties. Still, he wanted to continue working full time in this business as long as possible, despite the progressive nature of PD. When he was examined, he was found to have mild hypokinesia and bradykinesia as well as rigidity affecting his left side. He was at risk for sliding down the slippery slope of using his left hand less and less over time if left unchecked. With the goal of continuing to do everything he must do for his job, he was hooked.

In therapy, he practiced many functional work-related activities which require dual tasking and an extra layer of resistance and high-level balance challenges was added as it was relevant to his work demands. With this complex, purposeful and intensive training his confidence improved greatly. He felt empowered to continue to face the challenges of his job and to live well with PD. Since then, he has come back several times for a ‘tune-up’, and each time he has been able to tolerate even more challenges which were added to his home program.

3. Keep it simple

One thing many people do not fully understand is just how skewed perception of movement and posture is in people with PD! Internally, people with PD often feel like they are moving quite normally, when indeed, it is obvious to us that they are moving too small or too slow. Additionally, cognitive and executive functioning changes common in PD often impact the ability to attend to more than one cue or attend to complex cues. As we reflect on the wordy and complex explanations we used to provide when training our patients how to get up from a chair or don their jacket, for example, we now say “No wonder carryover was so challenging!”

We have since learned to keep our verbal cues very simple and redundant when providing LSVT BIG, focusing on a singular target of amplitude during exercise and functional training. The goal in LSVT BIG is to re-calibrate a person’s perception of movement so they can use this simple internal cue of “BIG” in everyday life no matter what the task.

When we really began to implement this approach, the results were remarkable. In many patients self-cueing mechanisms could actually be restored! They began to detect and correct their errors before we could open our mouths. We unanimously agree that this new way of teaching spilled over into other treatments we provided, making us more effective OTs than ever before.

4. Functional carryover is key!

Do you hypothetically talk about functional carryover or do rote exercises with the hope that improved function will naturally result?

Not surprisingly, the best way to improve occupational performance is to practice the actual task. To do this, we really need to dig in to discover what activities are the most meaningful and most important to the patient - and the patient alone (i.e. not the spouse, friend, relative, neighbor, etc.). What brings them joy? Taking the time to identify and train these activities has made all the difference in our treatment outcomes, our patients’ motivation and engagement not only during therapy, but with their home exercise
programs as well.

In LSVT BIG, we assign something called daily Carryover Assignments as a way to mandate the use of bigger, better quality movements in everyday life outside of therapy. For example, a person one of us worked with recently had planned to babysit her grandchildren and take them to the park one afternoon. She and the patient decided to assign “BIG pushing” of the swing with both hands to address the hypokinesia, while challenging her balance at the same time. This was enjoyable and meaningful to the patient and began to help her generalize what she learned in therapy to her life outside of therapy.

5. To restore or compensate? That is the question.

You probably hear the phrase “Exercise is medicine” frequently if you are an OT who works with older adults. Since we know this to be true from countless studies on the physiological benefits of exercise, we also know that exercise and early referral to therapy can help to slow down symptom progression in PD, restore function, and in some cases, temporarily eliminate disability. This is exciting considering that in the not too distant past, improvement in neural function in PD was thought to be impossible; bypassing the deficient basal ganglia had been our only hope. No more!

From another angle on this word “compensatory," OTs have always been geniuses in teaching patients how to use adaptive devices and clever compensatory techniques. While this is still true, one thing we all learned is that the use of adaptive devices may not even be needed in many cases!

For example, if we can adequately address the underlying deficit of hypokinesia by driving amplitude needed for a task such as buttoning, the patient can then perform this task without having to learn how to use buttonhook or avoid buttons altogether. And isn’t this what most patients ultimately desire - to simply do things the way they’ve always done them?