LSVT-BIG

= = **__ What is LSVT-BIG? __**

How it helps
LSVT-BIG is an exercise program that is used specifically to improve patients with Parkinson's Disease in the areas of movement speed, movement amplitude, gait form, balance, and quality of life (LSVT Global). LSVT stands for Lee Silverman Voice Treatment, now known as LSVT-LOUD, that specializes in speech rehabilitation for Parkinson's patients. LVST-LOUD focuses on intense and repetitive exercises training the larynx in order to allow patients with Parkinson's to have louder and clearer speech. These same principles were applied to limb and trunk movements with the goal of improving gait and movement in individuals with Parkinson's disease (PD) with LSVT-BIG. The principles behind LSVT-BIG are training patients specifically in the areas of increasing limb and body movement amplitude referred to in the program as "training bigness". This training shows marked improvements in amplitude in the areas of trunk rotation and flexibility, gait speed and form, balance, and overall quality of life. Patients who undergo the LVST-BIG program also find that they can maintain their improvements even when asked to multitask (LVST Global).

The Program
The program can be initiated by any LVST certified physical or occupational therapist. It takes place in sixteen sessions over the course of a month which breaks down to four 60 min sessions a week. The patient will undergo exercise instruction and implementation which focus on intense and complex repetitions in body core movements that often present themselves in daily actions of living. The goal of this program is to optimize the patient's learning of the exercises and movements so that the newly gained movement patterns are carried over into the patients daily life (LVST Global). Implementation of the program can begin at any point in the diagnosis of a PD patient. However, the sooner a patient starts the more success they are likely to have. This program is in no way meant to replace the use of effective medications in treating Parkinson's disease. Early on in PD diagnosis medications are usually very effective in treating symptoms and patients with PD can often cope with the changes in their activities of daily living (LSVT Global). However as the disease progresses coping can become more difficult and changes begin to influence the patient's life to a greater degree (Fox et al. 2015). The LVST-BIG program can help improve a patient's quality of life and manage their PD symptoms. Patients who start it early on in their diagnosis are also more likely to undergo and stick with the program and experience its benefits (LVST Global).

= = **__ Basal Ganglia __**

Basal Ganglia Anatomy
To understand how LSVT-Big exercises can help patients with Parkinson's recover movement ability it is first necessary to understand how the Basal Ganglia of the brain works normally and in Parkinson's patients. The Basal Ganglia are a collection of nuclei in the telencephalon, diencephalon, and mesencephalon of the brain. It consists of the caudate, putamen, globus pallidus, substantia nigra, and subthalmic nucleus (Figure 1). The globus pallidus is made up of two parts; the globus pallidus internus and the globus pallidus externus. The substantia nigra is also composed of two parts; the substantia nigra reticula and the substantia nigra compacta. The caudate, putamen, and globus pallidus together make up the corpus striatum (Figure 2). The nuclei of the basal ganglia work together to control and regulate movement, specifically facilitating "wanted" movement and preventing "unwanted" movements (Neuroscience Online). How this takes place is primarily though the Basal Ganglia's direct and indirect pathways.





= = **__ Neural Connections in the Basal Ganglia __**

Direct Pathway
The direct pathway is an excitatory pathway that aids in the facilitation of "wanted" movement. It does this primarily by releasing the thalamus of its resting or tonic inhibition, thus exciting it. The direct pathway begins in the sensorimotor cortex which excites the caudate and putamen (or corpus striatum) through the neurotransmitter glutamate (Figure 3). The corpus striatum when excited releases an inhibitory neurotransmitter known as GABA to the globus pallidus internus (GPi). Normally the GPi provides tonic inhibition to the thalamus when unaffected by either pathway. In other words the GPi is normally sending constant inhibitory signals to the thalamus, inhibiting it. In the direct pathway the GPi is inhibited by GABA released from the corpus striatum, thus it is prevented from inhibiting the ventral tier nuclei (in this case the thalamus). Since the thalamus is now freed of its normally tonic inhibition it can now release excitatory glutamate to excite the Sensory Motor Area (SMA), Pre-motor area (PM), and the Primary Motor Cortex (M1) in the Sensorimotor Cortex (Neuroscience Online).



Indirect Pathway
The indirect pathway is an inhibitory pathway that aids in the prevention of "unwanted" movement. It begins in the sensorimotor cortex which excites the caudate and putamen (or corpus striatum) through glutamate (Figure 3). In the indirect pathway the corpus striatum, once stimulated, releases inhibitory GABA to the Globus Pallidus externus (GPe) and inhibits it. Normally the GPe sends inhibitory signals to the Subthalamic Nuclei (STN). However, in the indirect pathway it's normal inhibition is inhibited by the corpus striatum. As a result the STN is freed from its inhibition and can release excitatory glutamate to the GPi. The GPi is then excited to release its tonic inhibitory signals through GABA to the ventral tier nuclei (or the thalamus). This results in the the thalamus sending inhibitory signals to the SMA, PM, and M1 and results in the prevention of unwanted movement (Neuroscience Online).

The Effects of Dopamine Receptors (Nigrostriatal Pathway)
There are additional effects on the direct and indirect pathways through the Nigrostriatal pathway. This pathway adds the effects of the neurotramnsmitter dopamine and two dopamine receptor types; dopaminergic neuron type 1 receptors (D1) and dopaminergic neuron type 2 receptors (D2) to the direct and indirect pathways (Figure 4). Influences from both D1 and D2 receptors work to excite the sensimotor cortex, and facilitate movement. In addition the nigrostriatum keeps the two pathways working with each other when movement is occurring. In the direct pathway, dopamine from the Substantia Nigra compacta (SNc) is released and interacts with D1 receptors on the corpus striatum causing a depolarization. As a result, there is excitation in the direct pathway and there is a reinforcement of the excitatory signals being sent to the sensorimotor cortex and movement is facilitated. In the indirect pathway, dopamine from the SNc interacts with D2 receptors on corpus striatum causing a hyperpolarization. As a result, there is an inhibition in the indirect pathway and the sensorimotor cortex is disinhibited and therefore excited. Once again movement is facilitated.



Parkinson's Disease
Parkinson's disease is defined as a neurological disorder that appears in motor and non-motor systems (Janssens et al. 2014). It is characterized by resting tremors, bradykinesia, muscle stiffness, and impaired posture/balance (Mayo Clinic). The effects of the disease can impair speech, swallowing, limb control and function, gait, balance, and activities of daily living (Fox et al. 2014). It is believed the Parkinson's Disease is the result of the degeneration of dopaminergic neurons in the SN which results in the symptoms characteristic to PD (Janssens et al. 2014). Figure 5 below shows the neural connections of a healthy unaffected individual. Figure 6 shows atrophy and disappearance of the SN in the neural connections of an individual with PD. As previously explained the Substanita Nigra plays a crucial role in both the direct and indirect pathways as well as the Nigrostriatal pathway. Normally through D1 receptors and dopamine the SNc excites the direct pathway and inhibits the indirect pathway. When the SNc is loss the normal balance of the two pathways becomes more weighted to the indirect pathway. The GPi becomes excessively active and abnormally inhibits the thalamus. This results in sensorimotor cortex neurons have a loss of excitation, or not being as stimulated as they normally are. As a result the motor system becomes less able to facilitate movement in the individuals environment.




 * __ LSVT-BIG Parkinson's Treatment __**

Movements with Parkinson's
Patients with Parkinson's disease experience difficulty in executing smooth movements. Those with PD execute movements with akinesia, bradykinesia, and hypokinesia (Fox et al. 2012). That is to say their movements are characterized as hesitant, slow, and with reduced amplitude. They have difficulty initiating movement and if movement is initiated it is abnormally slow and shaky (Neruoscience Online). Loss of balance and smooth execution of movements is also characteristic of patients with Parkinson's. Patients with PD often present trouble with walking (or gait), rising from chairs, turning corners, and postural control. They are also known to have uncoordinated movements and a lack of energy or motivation to accomplish activities of daily living (Salgado et al. 2013).



Movements with LSVT-BIG
With LSVT-BIG treatment patients learn to make large, deliberate, and exaggerated movements. It seeks to overcome slow speed and amplitude regulation in the movement of patients with PD (Fox et al. 2012). The positive impacts of LSVT-BIG exercise can persist for up to six months after the last day of its intervention (Dashtipour et al. 2015). Its goals are threefold. First it allows the patient to increase amplitude (or "bigness") in movement. Secondly it allows them to focus and recognize that their exaggerated movements learned through the program are within normal limits given their condition. Finally it allows the patient to train their attention to facilitate a long-term maintenance of the treatment's outcomes. In addition to these goals the treatment is also "consistent with principles that allow activity-dependent neuroplasticity and motor learning" (Fox et al. 2012). That is to say it helps restructure who gait and movements are processed in the brain. There are bodies of evidence that support the impact of LSVT-BIG exercise on the brain. Studies have shown that it can result in increasing synaptogenesis and neurotrophic factors (Dashtipour et al. 2015). When actions become habitual and unconscious they are often implemented in the Basal Ganglia (Neuroscience Online). Gait can easily fall within this category and it is no wonder why patients with PD have trouble with this task when their is damage to their Basal Ganglia. However, part of LSVT-BIG treatment is training actions normally unconscious, like gait, to be thoughtful and purposeful actions and therefore conscious. Patients are encouraged to count steps and think more closely about how they are walking. The cognitive centers behind implementing this kind of movement are found within the cortex. Repetitive, deliberate, and exaggerated movements help the patient focus on what they are doing. This in turn moves the processing for movement to higher cognitive centers like the cortex. By by-passing processing in the damaged basal ganglia and instead having gait go through processing in the unaffected cortex, patients can markedly improve in the smoothness, intentionality, and degree of their movements. Numerous studies have found that after LSVT-BIG therapy subjects have significant increases in reaching speed and gait. In addition, while all individuals, regardless of their PD progression, see some improvement the most improvement is seen in individuals where the severity of the disease is less. (Farley et al. 2005).

**__ Summary __** While LSVT-BIG treatment is not a cure for Parkinson's disease, it can certainly help a patient move more efficiently, manage their symptoms, and achieve their activities of daily living with a greater degree of success. The therapy primarily focuses on training patients to make large, exaggerated movements of high amplitude in order to help compensate for the disruption in their Basal Ganglia resulting in slow, small, shaky, and hesitant movements. It can also help with motor learning and neuroplasticity which helps the patient move gait into their conscious movement associated with their cortex and away from their disrupted Basal Ganglia which is associated with unconscious movement. Through this program patients are able to walk with more stability, speed, and control. In addition they can experience increased trunk and core flexibility as well as postural control.

**__ Glossary Terms __**
 * Akinesia
 * Hesitance in movements
 * Bradykinesia
 * Slowness in movements
 * Hypokinesia
 * Reduced amplitude in movements
 * Disinhibition
 * A releasing from inhibition

**__ Examples and Recommended Readings __**

Videos
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Readings
__LVST Global__ http://www.lsvtglobal.com/patient-resources/what-is-lsvt-big

**__ Quiz __**

Multiple Choice
1. Patients with Parkinson's Disease would have trouble with which of the following aspects of gait? A - Balance B - Proprioception C - Stride Frequency D - Stride Length E - A&B F - A&C G - A&C&D H - All of the above

2. LSVT-BIG exercises focuses on enhancing what areas of movement? A - Amplitude B - Speed C - Efficiency D - A&B E - A&C F - A&B&C G - None of the above H - All of the above

3. LSVT-BIG results in improvements for patients... A - With an early diagnosis of PD B - Patients with a standing diagnosis of PD C - Patients not yet diagnosed but exhibiting symptoms of PD D - A&B E - A&C F - B&C G - All of the above

4. The effect of dopamine on the direct and indirect pathways results in... A - An excitatory effect on the direct pathway B - A inhibitory effect on excitation the indirect pathway C - An inhibitory effect on the inhibition of the indirect pathway D - A&B E - A&C F - All of the above G - None of the above

5. In patients with PD, the nigrostriatal pathway is affected in what way(s)? A - Loss of the effect of the indirect pathway B - Loss of the effect of the direct pathway C - Loss of the D2 receptor inhibitory effect on the direct pathway D - Loss of the D1 receptor excitatory effect on the indirect pathway E - A&C F - B&D G - A&B H - C&D

T/F

 * 1) Parkinson's Disease primarily effects the higher areas of the brain, such as the cortex.
 * 2) The effect of dopamine on the indirect pathway facilitates the disinhibition of movement.
 * 3) LSVT-BIG does not have a marked effect on improving movements in patients who've had a long-term existing diagnosis of PD.

Short Answer

 * 1) How is the Basal Ganglia affected in patients with Parkinson's?
 * 2) How does LSVT-BIG exercises help patients with Parkinson's in terms of gait?
 * 3) What is the role of motor learning in LSVT-BIG Parkinson's treatment?

**__ References __**

Journal Articles

 * Fox, C., Ebersbach, G., Ramig, L., & Sapir, S. (2012). LSVT LOUD and LSVT BIG: behavioral treatment programs for speech and body movement in Parkinson disease. //Parkinson’s disease //, //2012 //.
 * Farley, B. G., & Koshland, G. F. (2005). Training BIG to move faster: the application of the speed–amplitude relation as a rehabilitation strategy for people with Parkinson’s disease. //Experimental Brain Research //, //167 //(3), 462-467.
 * Janssens, J., Malfroid, K., Nyffeler, T., Bohlhalter, S., & Vanbellingen, T. (2014). Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with Parkinson disease: a case series. //Physical therapy //, //94 //(7), 1014-1023.
 * Dashtipour, K., Johnson, E., Kani, C., Kani, K., Hadi, E., Ghamsary, M., ... & Chen, J. J. (2015). Effect of exercise on motor and nonmotor symptoms of Parkinson’s disease. //Parkinson’s Disease //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">, //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">2015 //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">.
 * <span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">Salgado, S., Williams, N., Kotian, R., & Salgado, M. (2013). An evidence-based exercise regimen for patients with mild to moderate Parkinson’s disease. //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">Brain sciences //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">, //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">3 //<span style="background-color: #ffffff; color: #222222; font-family: Arial,sans-serif;">(1), 87-100.

Other

 * LVST Global
 * http://www.lsvtglobal.com/patient-resources/what-is-lsvt-big
 * Knierim, James, P.h.D. "Chapter 4: Basal Ganglia." // Neuroscience Online // . The University of Texas Medical School, n.d. Fri. 25 Nov. 2016. <[]>.
 * Understanding Parkinson's." // Parkinson's Disease Foundation // . Parkinson's Disease Foundation Inc., 2015. Fri. 25 Nov. 2016. <[]>.
 * Mayo Clinic. "Parkinson's Disease." // - Mayo Clinic // . Mayo Foundation for Medical Education and Research, 7 July 2015. Fri. 25 Nov. 2016. <[]>.

Images

 * Figure 1
 * Neuroscience Online, Chapter 4: Basal Ganglia
 * http://neuroscience.uth.tmc.edu/s3/chapter04.html
 * Figure 2
 * Slideshare: Descending Tracts
 * http://www.slideshare.net/christinegendy/neuro-13-descending-tracts-student
 * Figure 3
 * KIN 450 Wikipage
 * https://kin450-neurophysiology.wikispaces.com/Parkinson's+Disease
 * Figure 4
 * Neuroscience Online, Chapter 4: Basal Ganglia
 * http://neuroscience.uth.tmc.edu/s3/chapter04.html
 * Figure 5
 * Neuroscience Online, Chapter 4: Basal Ganglia
 * http://neuroscience.uth.tmc.edu/s3/chapter04.html
 * Figure 6
 * Neuroscience Online, Chapter 4: Basal Ganglia
 * http://neuroscience.uth.tmc.edu/s3/chapter04.html
 * Figure 7
 * The Longevity Network
 * http://www.longevitynetwork.org/news/great-strides-smartphone-app-may-prevent-dangerous-freezing-of-gait-in-parkinsons-patients/

Videos

 * LSVT Big program
 * https://youtu.be/nPmPCa1H3hU
 * think BIG ! - how i fight Parkinson's with LSVT BIG
 * https://youtu.be/cV8FjbC_MMw
 * LSVT BIG therapy for people Parkinson's disease
 * https://youtu.be/wElz9jNrqns

__** Quiz Answers **__ ** Multiple Choice Answers **
 * G
 * D
 * G
 * E
 * C

True/False Answers

 * F
 * T
 * F