Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis

Exploring Potential Predictors of Treadmill Training Effects in People With Parkinson Disease

OBJECTIVE

To explore the potential predictors of people with Parkinson disease (PD) who would benefit the most from treadmill training.

DESIGN

A cohort study.

SETTING

Medical university rehabilitation settings.

PARTICIPANTS

Seventy participants diagnosed of idiopathic PD.

INTERVENTIONS

Twelve sessions of treadmill training.

MAIN OUTCOME MEASURES

Hierarchical logistic regression models were used to explore significant predictors of the treadmill training effect with respect to 3 health domains: Unified Parkinson's Disease Rating Scales part III (UPDRS III); gait speed; Parkinson's Disease Questionnaire-39 (PDQ-39). A receiver operating characteristic (ROC) curve analysis was conducted to identify proper cut-off points for clinical use.

RESULTS

Male sex (adjusted odds ratio [OR]: 3.73, P=.036) significantly predicted the improvement of UPDRS III. Individuals with a slower baseline gait speed (cut-off: 0.92 m/s, adjusted OR: 14.06, P<.001) and higher baseline balance confidence measured by the Activity-specific Balance Confidence scale (cut-off: 84.5 points, adjusted OR: 4.66, P=.022) have greater potential to achieve clinically relevant improvements in gait speed. A poorer baseline PDQ-39 score (cut-off: 23.1, adjusted OR: 7.47, P<.001) predicted a greater quality of life improvement after treadmill training.

CONCLUSIONS

These findings provide a guideline for clinicians to easily identify suitable candidates for treadmill training. Generalization to more advanced patients with PD warrants further investigation.

The effects of standard and modified LSVT BIG therapy protocols on balance and gait in Parkinson's disease: A randomized controlled trial

BACKGROUND

Lee Silverman voice treatment (LSVT) BIG is an exercise program developed for patients with Parkinson's disease (PwPD), consisting of sets of exercises performed for 4 consecutive days a week for 4 weeks. However, the standard protocol suggests a treatment frequency difficult to follow for most patients who have difficulties reaching rehabilitation clinics. Our aim was to compare the standard LSVT BIG protocol with a modified LSVT (m-LSVT) BIG protocol (twice a week in the clinic for 4 weeks and twice a week at home for 4 weeks).

METHODS

In this randomized controlled trial, 16 PwPD (aged 18-80 years, Hoehn and Yahr stages I-III) were recruited into two groups. The LSVT group received standard LSVT BIG training (four times per week for 4 weeks at the clinic). The other group was given m-LSVT BIG exercises, but unlike the LSVT group, the m-LSVT group exercised twice a week at the clinic and twice a week at home for 4 weeks. The Berg Balance Scale was used to assess functional balance. Biodex Balance System was used to assess laboratory balance measures. Timed Up and Go test and G-Walk sensor system were used to assess functional mobility and spatiotemporal gait analysis.

RESULTS

Significant group-by-time interactions on the eyes open-firm surface score of the modified clinical test of sensory integration of balance (F = 10.138, p = .007) and gait cycle symmetry index (F = 10.470, p = .010) were found to be in favor of the LSVT group. Additionally, post hoc analyses revealed that both groups significantly improved postural stability, gait speed, motor symptoms, and functional mobility (p < .05).

CONCLUSION

The results revealed the beneficial effects of the modified protocol on balance and gait in PwPD, as well as the superiority of the standard LSVT BIG protocol. The m-LSVT BIG protocol may be an effective intervention method, especially for PwPD who have difficulty adapting to the treatment frequency of the standard protocol.

Specialized Allied Health Care for Parkinson's Disease: State of the Art and Future Directions

People with Parkinson's disease (PD) experience a range of progressive motor and non-motor symptoms, that negatively affect their daily functioning, social participation and quality of life. Allied health therapies have emerged as an effective treatment approach-complementary to pharmacological and neurosurgical treatments-which reduces the impact of PD in daily life. In this article, we propose criteria for what constitutes specialized allied health care for PD, and we review allied health research in PD in terms of meeting these criteria and its outcomes for monodisciplinary approaches as well as multi- or interdisciplinary allied health interventions. We focus on the three most studied allied health disciplines in PD: physical therapy, occupational therapy and speech-language therapy. Overall, the available evidence underscores the importance and potential benefits of specialized allied health care for people with PD. Our proposed criteria and recommendations for future research might help in further delineating specialized allied health care.

Cost-Effectiveness Analyses of Non-Pharmacological and Non-Surgical Interventions in Idiopathic Parkinson's Disease: A Systematic Review

Background

Interest in non-pharmacological/non-surgical interventions to treat Parkinson's disease (PD) has substantially increased. Although a few health-economic studies have been conducted, summary information on the cost-effectiveness is still scarce.

Objective

To give an overview of cost-effectiveness analyses (CEA) focusing on non-pharmacological/non-surgical interventions in PD patients.

Methods

A systematic literature search was conducted in five databases. Studies were included that provided cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) of non-pharmacological/non-surgical interventions in PD patients. Study quality was assessed with the Drummond and CHEERS 2022 checklists, respectively for economic evaluation.

Results

N = 9 studies published between 2012-2023 were identified. Most studies undertook a CUA (n = 5); n = 3 reported a combination of CEA and CUA, and n = 1 a pure CEA. Most studies (n = 6) examined physical exercise. The CEA studies identified additional costs of 170€ -660€  for the improvement of one single unit of a clinical outcome and savings of 18.40€ -22.80€  per score gained as measured with established instruments. The four studies that found significant quality of life benefits show large variations in the incremental cost effectiveness ratio (ICER) of 3,220€ -214,226€  per quality-adjusted life year (QALY); notably interventions were heterogenous regarding content and intensity.

Conclusions

Despite increasing numbers of non-pharmacological/non-surgical intervention trials in PD patients, health-economic evaluations are rare. The examined intervention types and health-economic results vary greatly. Together with the heterogeneity of the health-economic studies these factors limit the conclusions that can be drawn. Further research and a standardization of methods is needed to allow decision makers to make meaningful interpretations, and to allocate scarce resources.

Physical exercise and its effects on people with Parkinson's disease: Umbrella review

INTRODUCTION

Parkinson's disease is neurodegenerative, complex and progressive, manifesting in a slow and irreversible way. Physical exercise has been proposed as therapeutic alternative to people with Parkinson´s disease.

OBJECTIVE

To synthesize knowledge about the effects of physical exercise on people with Parkinson´s Disease as presented by published systematic reviews.

METHODS

Nine electronic databases and two grey literature databases were searched for systematic reviews reporting the effects of physical exercises on people with Parkinson´s Disease. Searches involved a two-phase process, by, at least, two independent reviewers. Methodological quality of the included systematic reviews was assessed using AMSTAR-2.

RESULTS

From 2,122 systematic reviews, 139 were included. Motor outcomes were assessed in 91% of the studies, with balance being the most studied. Non-motor outcomes were assessed in 68% of the studies, with emphasis on quality of life. Physical exercises were classified into five categories: aerobic exercises, strength, combined, sensorimotor activities and other activity protocols. Findings of the systematic reviews suggest that all exercise categories can be prescribed to improve balance and mobility, while combined exercises, strength, and specific activities improve both motor and non-motor outcomes, and aerobic exercise and sensorimotor activities improve motor outcomes.

CONCLUSION

Current evidence from systematic reviews suggests that physical exercises impacts both motor and non-motor outcomes in people with Parkinson´s Disease. Limits in evidence provided by the systematic reviews were related to methodological issues and to the description of the interventions and must be considered to improve decision-making and clinical application.

Quantitative assessment of the gait improvement effect of LSVT BIG® using a wearable sensor in patients with Parkinson's disease

Background

The main effects of Lee Silvermann Voice Treatment-BIG® therapy (LSVT-BIG) on gait function are improvements in gait speed and stride length. Considering the mechanism of this improvement, LSVT-BIG may affect joint angles of the lower extremities. Therefore, further investigation of the effect of LSVT-BIG on gait function, especially joint angles, is needed.

Methods

Patients with Parkinson's disease (PD) who were eligible for LSVT-BIG were recruited. We measured the following items pre- and post-LSVT-BIG: MDS-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Functional Independence Measure (FIM), timed up and go test (TUG), and gait parameters using RehaGait®. Gait parameters included gait speed, stride duration and length, the standard deviation of stride duration and length, cadence, the ratio of the stance/swing phase, and the flexion and extension angles of the hip, knee, and ankle joints. Range of motion (ROM) was calculated as the difference of values between the maximum flexion and extension angles of each joint.

Results

Twenty-four participants completed the LSVT-BIG. Significant improvement was observed in the MDS-UPDRS (mean changes: Part I, -2.4 points; Part II, -3.5 points; Part III -8.9 points), TUG (-0.61 s), gait speed (+0.13 m/s), stride length (+0.12 m), flexion and extension angles and ROM of the hip joints (flexion, +2.0°; extension, +2.0; ROM, +4.0°). Enlargement in ROM of the hip joint was strongly correlated with increase in gait speed and stride length (r = 0.755, r = 0.804, respectively).

Conclusions

LSVT-BIG enlarged flexion and extension angles and ROM of the hip joint significantly. Change of ROM of the hip joint was directly related to the increase in stride length and gait speed observed in patients with PD after LSVT-BIG.

Parkinson's disease - current treatment

PURPOSE OF REVIEW

The purpose is to review the results and impact of recent studies for current and future treatment of both motor and non-motor symptoms in Parkinson's disease (PD).

RECENT FINDINGS

New formulations of levodopa further optimize motor fluctuations, allowing for more on-time and less dyskinesia. On demand apomorphine continues to showcase itself as an effective and tolerable tool for treating motor off-periods. Though there are no clear treatment guidelines for PD-related constipation and sleep related disorders, several new agents for these non-motor symptoms show promising preliminary data. Expiratory muscle strength training may represent a useful and cost-effective strategy to alleviate oropharyngeal dysphagia associated with PD. There is evidence to suggest that the use of shorter pulse width and directional deep brain stimulation leads can results in a greater therapeutic window.

SUMMARY

Though no interventions currently exist to significantly modify the disease progression of PD, new studies continue to give insight into optimal symptomatic management. Clinicians should be familiar with expanding the repertoire of tools available to treat the diverse range of symptoms and challenges associated with PD.

The effect of physical exercise on anxiety in people with parkinson’s disease: A systematic review of randomized control trials

BACKGROUND Anxiety is a prominent disabling non-motor neuropsychiatric complication of Parkinson’s disease (PD). Pharmacological treatments for PD and anxiety have drug interactions and negative side effects. Therefore, non-pharmacological interventions such as exercise has been proposed to reduce anxiety in people with PD (PwP). OBJECTIVE This systematic review aimed to explore the relationship between physical exercise and anxiety in PwP. METHOD Four databases (PubMed, Embase, Scopus, Ebscohost) were searched without date restrictions. English randomized control trials (RCT) including adults with PD, exposed to physical exercise interventions with anxiety as an outcome variable, were included. Quality was assessed by means of an adapted 9-point PEDro scale. RESULTS Five of the identified 5547 studies met the inclusion criteria. Sample size ranged between 11–152 participants, totaling 328 participants with majority being male. PD stage ranged from early to moderate, with disease duration ranged between 2.9 and 8.0 years. All studies measured anxiety at baseline and post-intervention. On average studies scored 7/9 (76%) on the PEDro scale. CONCLUSION There is insufficient evidence to support or refute the effect of exercise on anxiety in PwP due to noted limitations of included studies. There is an urgent need for high-quality RCTs on physical exercise and anxiety in PwP.

Effects of Popping For Parkinson’s dance class on the mood of people with Parkinson’s disease

Background/Aims

Depression, low mood and apathy can affect people with Parkinson’s disease, impacting on their quality of life. The aim of this study was to investigate the effects of one Popping For Parkinson’s dance session on the mood of people with Parkinson’s disease.

Methods

A total of 33 people with Parkinson’s disease, with a mean age of 67.5 years (standard deviation 10.3 years), mean Parkinson’s level of 1.8 (standard deviation 1.6), took part in one Popping For Parkinson's dance class at four different locations: London (UK), Hatfield (UK), New York City (USA) and Turin (Italy). Participants’ mood was measured with the Profile of Mood States questionnaire at four time points: immediately before the dance class, immediately after the dance class, 24 hours after the dance class and 1 week after the dance class.

Results

Participants’ total mood score and the subscale score of vigour increased, while the subscales of tension, depression, and confusion decreased on the Profile of Mood States, significantly immediately after the dance intervention. However, at 24 hours and 1 week after the dance class, mood scores did not differ significantly compared with baseline measurements. The improvements in mood immediately after the dance class did not differ depending on sex, age, previous dance experience, the location of the dance class, stage of Parkinson’s disease, presence of tremor and deep brain stimulation treatment.

Conclusions

Participating in a Popping For Parkinson’s dance class boosts mood in the short term, and this improvement lasts less than 24 hours. This finding has implications for the provision of dance classes, suggesting that regular attendance may be necessary for sustained improvements. Further studies are needed to determine whether attending a series of Popping for Parkinson’s classes may have longer-term effects.

Rehabilitating Cough Dysfunction in Parkinson's Disease: A Randomized Controlled Trial

BACKGROUND

Disorders of airway protection (cough and swallowing) are pervasive in Parkinson's disease (PD) resulting in a high incidence of aspiration pneumonia and death. However, there are no randomized controlled trials comparing strength and skill-based approaches to improve airway protection in PD.

OBJECTIVES

The aim of this study was to compare expiratory muscle strength training (EMST) and sensorimotor training for airway protection (smTAP) to improve cough-related outcomes in people with PD.

METHODS

Participants with PD and dysphagia were recruited for this prospective phase II randomized-blinded controlled clinical trial. Participants completed baseline assessment, 5 weeks of EMST or smTAP, and a post-training assessment. Primary outcome measures included maximum expiratory pressure (MEP) and voluntary cough peak expiratory flow rate (PEFR). Mixed effects models were used to assess the effects of EMST and smTAP on outcomes.

RESULTS

A total of 65 participants received either EMST (n = 34) or smTAP (n = 31). MEP improved from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.53). Voluntary PEFR increased from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.06). Moreover, reflex cough PEFR (P < 0.001, d = 0.64), reflex cough expired volume (P < 0.001, d = 0.74), and urge to cough (P = 0.018, OR = 2.70) improved for the smTAP group but not for the EMST group.

CONCLUSIONS

This clinical trial confirmed the efficacy of smTAP to improve reflex and voluntary cough function, above and beyond EMST, the current gold standard. © 2022 International Parkinson and Movement Disorder Society.

Effects of LSVT-BIG via telerehabilitation on non-motor and motor symptoms and quality of life in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease with motor and non-motor symptoms affecting the quality of life. This study aimed to investigate the effects of the Lee Silverman Voice Therapy (LSVT)-BIG rehabilitation program via telerehabilitation on quality of life, motor and non-motor symptoms in people with Parkinson's disease (PwPD), and their correlation with each other.

METHODS

Fifteen patients with mild-to-moderate PD (Hoehn and Yahr stages 1-3) were included in the LSVT-BIG exercise program with remote access for 16 sessions over four weeks. Motor and non-motor experiences before and after the program were evaluated with MDS-UPDRS parts 1, 2, and 3 and quality of life with PDQ-39. The correlation between MDS-UPDRS parts and PDQ-39 subgroups was examined.

RESULTS

Following the application of the LSVT-BIG rehabilitation program with remote access, MDS-UPDRS parts 1, 2, and 3 scores and PDQ-39 summary index (PDQ-39 SI) and subgroup scores (excluding social support) were improved. A moderate-strong correlation was determined between MDS-UPDRS parts 1 and 2 and the PDQ-39 parameters of the patients.

CONCLUSION

Both motor and non-motor symptoms may be associated with the quality of life in PD. We have concluded that LSVT-BIG treatment via telerehabilitation can improve motor and non-motor symptoms along with the quality of life in PwPD.

Impact of LSVT-BIG ® on functional mobility, walking, dexterity, and quality of life in Parkinson's disease

Purpose: The aim of this study was to evaluate the impact of the LSVT-BIG ® (Lee Silverman Voice Treatment Big) technique on functional mobility, dexterity, and quality of life in Parkinson's disease (PD). Materials and Methods: Fifteen patients with Parkinson's disease (9 males, and 6 females, aged 40-75 years; Hoehn & Yahr Stages I-III) completed a 4-week LSVT-BIG training program for 1 hour/session, 4 sessions per week. Parkinson's Disease Quality of Life Questionnaire-39 (PDQ-39) was used in measuring patients' quality of life at the beginning (t0) and at the end (t1) of the rehabilitation program. Nine-Hole Peg Test (NHPT) was used for dexterity. 10 Meter Walking Test (10MWT), Timed-Up-and-Go Test (TUG), and Five-Times Sit-to-Stand Test (5XSST) were used for assessing functional mobility. After 4 weeks, all participants were retested. Results: After 4 weeks of LSVT-BIG therapy, a statistically significant improvement was found in PDQ-39 mobility, activities of daily living, emotional state, stigma, cognition, communication, physical discomfort, and general scores after exercise compared to before. There was no statistically significant change in the PDQ-39 social support score after exercise compared to before. In addition, functional mobility improved as indicated by the TUG test, 5XSST, 10MWT (and dexterity by NHPT on the left. Conclusion: LSVT-BIG training may be a new therapeutic option for better walking, functional mobility, and manual capability performance and for enhancing the quality of life in PD. Randomized controlled trials with bigger sizes are needed to evaluate the effect of the LSVT-BIG rehabilitation program on reducing motor and non-motor impairments in patients with PD.

Effects of Task-Based LSVT-BIG Intervention on Hand Function, Activity of Daily Living, Psychological Function, and Quality of Life in Parkinson’s Disease: A Randomized Control Trial

Previous studies have demonstrated that the Lee Silverman Voice Treatment-BIG (LSVT-BIG) program can improve motor functions such as balance and gait in Parkinson’s disease (PD) patients. However, no study has investigated the effects of a task-based LSVT-BIG intervention on hand function, psychological function, and quality of life in PD patients. Herein, we investigate the effects of a task-based LSVT-BIG intervention, which reflects the needs of PD patients, on hand function, activity of daily living (ADL), psychological function, and quality of life. A total of 14 PD patients were enrolled and randomly assigned to the experimental or control group. The experimental group performed 30 minutes of conventional occupational therapy and 40 minutes of the task-based LSVT-BIG program. The control group performed 30 minutes of conventional occupational therapy and 40 minutes of relaxation and stretching. Both groups underwent the respective interventions once a day 5 times a week for 4 weeks. As a result of the study, the experimental group showed improvement in hand function in both the dominant and nondominant hand, and the control group showed improvement only in the nondominant hand ( $p<.05$ ). ADL was significantly improved in both groups, but the experimental group showed a more statistically significant difference than the control group ( $p<.05$ ). Depression and anxiety were significantly decreased in both the experimental group and the control group, and in particular, in the case of anxiety, there was a more statistically significant difference in the experimental group ( $p<.05$ ). In the case of the experimental group, there was a significant improvement in quality of life in all items, and in the control group, except for the social function item ( $p>.05$ ), there was a significant improvement in other items ( $p<.05$ ). The results of this study suggest that the task-based LSVT-BIG program, which consists of activities desired by the participants, may be an effective intervention to improve hand function, ADL, psychological function, and quality of life in PD patients.

Efficacy of Wearable Device Gait Training on Parkinson's Disease: A Randomized Controlled Open-label Pilot Study

Objective To investigate the efficacy of home-based gait training using the wearable Stride Management Assist (SMA) exoskeleton in people with moderately advanced Parkinson's disease. Methods This was a single-center, open-label, parallel, randomized controlled trial. We included outpatients with idiopathic Parkinson's disease who were capable of walking independently with or without walk aids and had Hoehn and Yahr stage 2-4 in the ON state. Patients were randomly assigned (1:1 ratio) to receive either SMA gait training (SMA group) or control gait training (control group). All participants underwent gait training for approximately 30 min. These training sessions were conducted 10 times for 3 months. We measured clinical outcomes at baseline and post-intervention. The between-group difference of distance in the three-minute walk test was the primary outcome. Results Of the 15 randomly assigned participants, 12 (five in the SMA group) completed this study. The between-group difference was a mean of 13.7 meters (standard error of the mean: 7.8) in the 3-minute walk test (p=0.109). The distance traversed increased from 141.4 m to 154.7 m in the SMA group (p=0.023), whereas there was no marked change in the control group. In addition, although there was a decrease in the physiological cost index from 0.29 to 0.13 in the SMA group (p=0.046), it remained unchanged in the control group. Conclusion These findings suggest that home-based SMA gait training may increase the exercise endurance in people with moderately advanced Parkinson's disease.

Occupational Therapy Practice Guidelines for People With Parkinson's Disease

IMPORTANCE

Occupational therapy practitioners address the occupational performance and participation needs of people with Parkinson's disease (PD) and their care partners.

OBJECTIVE

This Practice Guideline is informed by systematic reviews on the use of occupational therapy interventions to promote participation in occupations for people with PD and to facilitate their caregivers' participation in the caregiver role. This guideline is meant to support practitioners' clinical decision making when working with people with PD and their care partners.

METHOD

We examined and synthesized the results of four systematic reviews and integrated those results into clinical recommendations for practice.

RESULTS

Thirty-three articles from the systematic reviews served as the basis for the clinical recommendations in this Practice Guideline. Clinical recommendations are provided for interventions that have strong or moderate supporting evidence.

CONCLUSION AND RECOMMENDATIONS

Multidisciplinary, tailored, goal-oriented intervention is recommended for people with PD. Various forms of exercise can be used to improve activities of daily living and instrumental activities of daily living performance and social participation, and interventions should incorporate health behavior change techniques to support adequate physical activity levels in daily life. Mindfulness meditation and exercise can be used to support sleep, and task-oriented training can be used to improve performance of specific tasks. Occupational therapy practitioners should incorporate self-management, coaching, compensatory, cognitive-behavioral, and other approaches into multicomponent treatment plans depending on the client's needs and goals. Additional potentially appropriate intervention approaches or areas to address are discussed on the basis of existing or emerging evidence and expert opinion. What This Article Adds: This Practice Guideline provides a summary and applications of the current evidence supporting occupational therapy intervention for people with PD. It includes case examples and suggested decision-making algorithms to support practitioners in addressing client goals.

Novel insights into the effects of levodopa on the up- and downstrokes of writing sequences

Motor control of automatized and overlearned sequences, such as writing, is affected in Parkinson's disease (PD), impacting patients' daily life. Medication effects on motor performance are not only task-specific, but also variable within tasks. The nature of this variance is still unclear. This study aimed to investigate whether medication affects writing sequences differently when producing up- or downstrokes. Writing was assessed in healthy controls (HC) (N = 31) and PD (N = 32), when ON and OFF medication in a randomized order (interspersed by two months). Subjects wrote a sequential pattern with an increasing size on a digital tablet. Writing outcomes were movement vigor (amplitude and velocity), error and end-point variability, and sequence continuation, calculated separately for up- and downstrokes. Results showed that PD patients OFF-medication reduced movement vigor (amplitude) for up- and downstrokes compared to HC. Clear deficits were found for up- but not for downstroke error in PD patients in OFF, suggesting a directional bias. Dopaminergic medication improved motor vigor by increasing writing amplitude and upstroke continuation, but this occurred at the cost of the downstroke trajectory. Other writing outcomes did not improve with medication intake. In conclusion, we interpret these findings as that the impact of dopamine is complex, highly task-specific, supporting the most highly energy demanding components of a writing sequence. As medication did not regulate downstroke writing, we recommend supplementary training to address task demands that were less modulated by dopamine (registration: https://osf.io/gk5q8/ , 17 July 2018).

Occupational Performance and Hand Function in People With Parkinson's Disease After Participation in Lee Silverman Voice Treatment (LSVT) BIG®

IMPORTANCE

People with Parkinson's disease (PD) experience motor and functional impairment that can negatively affect daily living and participation.

OBJECTIVE

To examine the occupational performance and hand function outcomes of people with PD who participated in a Lee Silverman Voice Treatment (LSVT) BIG® program.

DESIGN

Retrospective record review.

SETTING

Outcomes were extracted from patient charts at a hospital outpatient clinic.

PARTICIPANTS

Sixty-six clinic outpatients with PD who completed the LSVT BIG program.

INTERVENTION

An occupational therapist and a physical therapist who were certified in LSVT BIG administration delivered the 16-session LSVT BIG program. Outcomes and Measures: The Canadian Occupational Performance Measure (COPM), grip strength, and Minnesota Manual Dexterity Test (MMDT) were administered before and after participation in LSVT BIG training.

RESULTS

For participant-identified COPM goals, pre-post changes were significant, ranging from 3 to 6 points for performance and satisfaction (p < .001). Grip strength in both hands showed significant gains; median scores for the right hand increased from 55.0 lb (interquartile range [IQR] 41.0, 70.0) to 64.0 lb (IQR 46.0, 80.0; p < .001) and for the left hand from 52.0 lb (IQR 39.0, 64.0) to 63.0 lb (IQR 44.5, 79.5; p < .001). MMDT median scores for right to left also significantly improved, from 124.0 s (IQR 113.0, 181.0) to 119.5 s (IQR 105.5, 163.5; p = .014).

CONCLUSIONS AND RELEVANCE

Participation in the LSVT BIG program can improve perceived occupational performance and satisfaction and produce gains in hand strength and dexterity for people with PD. What This Article Adds: This study is the first retrospective review of data on occupational performance and hand function outcomes after participation in the LSVT BIG program. The findings of beneficial outcomes support the use of LSVT BIG in occupational therapy services to increase functional abilities among people with PD.

Early implementation of intended exercise improves quality of life in Parkinson's disease patients

OBJECTIVE

Recent data have shown that regular exercise may ameliorate motor symptoms in Parkinson's disease (PD). This study aims to investigate how intended exercise impacts motor and non-movement symptoms of PD.

METHODS

Eighty-eight patients were randomly assigned to an early exercise group (E-EG), late exercise group (L-EG), or a control group (CG) using a randomized delayed-start design. The E-EG carried out a rigorous, formal exercise program for 1 h, twice per week, for 18 months (May 2018-November 2019). The L-EG took part in the exercise program in the final 6-12 months of the study. We assessed outcomes using the Unified Parkinson's Disease Rating Scale (UPDRS), PDQ-39 Questionnaire, Line A test, Line B test, Nine-hole column test, 30 s squat and stand-up test (30 s SST), 10-m walk test (10mW), Balance Evaluation Systems Mini Test (MiniBESTest), FAB, and Time Up and Go Test (TUG).

RESULTS

The patients with PD in the E-EG had lower performance in the UPDRS and Line B test compared to those in the L-EG at post-exercise (p < 0.05). Moreover, the patients with PD in the E-EG had much lower performance in the PDQ-39 and 9-Hole Peg test compared to those in the L-EG at post-exercise (p < 0.01).

CONCLUSION

Implementation of an exercise regimen improved the movement abilities and quality of life in PD patients, especially in the E-EG. This data supports the idea that intended exercise should be implemented as part of the treatment strategy for PD patients as early as possible.

Parkinson's disease

Parkinson's disease is a recognisable clinical syndrome with a range of causes and clinical presentations. Parkinson's disease represents a fast-growing neurodegenerative condition; the rising prevalence worldwide resembles the many characteristics typically observed during a pandemic, except for an infectious cause. In most populations, 3-5% of Parkinson's disease is explained by genetic causes linked to known Parkinson's disease genes, thus representing monogenic Parkinson's disease, whereas 90 genetic risk variants collectively explain 16-36% of the heritable risk of non-monogenic Parkinson's disease. Additional causal associations include having a relative with Parkinson's disease or tremor, constipation, and being a non-smoker, each at least doubling the risk of Parkinson's disease. The diagnosis is clinically based; ancillary testing is reserved for people with an atypical presentation. Current criteria define Parkinson's disease as the presence of bradykinesia combined with either rest tremor, rigidity, or both. However, the clinical presentation is multifaceted and includes many non-motor symptoms. Prognostic counselling is guided by awareness of disease subtypes. Clinically manifest Parkinson's disease is preceded by a potentially long prodromal period. Presently, establishment of prodromal symptoms has no clinical implications other than symptom suppression, although recognition of prodromal parkinsonism will probably have consequences when disease-modifying treatments become available. Treatment goals vary from person to person, emphasising the need for personalised management. There is no reason to postpone symptomatic treatment in people developing disability due to Parkinson's disease. Levodopa is the most common medication used as first-line therapy. Optimal management should start at diagnosis and requires a multidisciplinary team approach, including a growing repertoire of non-pharmacological interventions. At present, no therapy can slow down or arrest the progression of Parkinson's disease, but informed by new insights in genetic causes and mechanisms of neuronal death, several promising strategies are being tested for disease-modifying potential. With the perspective of people with Parkinson's disease as a so-called red thread throughout this Seminar, we will show how personalised management of Parkinson's disease can be optimised.

A randomised controlled trial on effectiveness and feasibility of sport climbing in Parkinson's disease

Physical activity is of prime importance in non-pharmacological Parkinson's disease (PD) treatment. The current study examines the effectiveness and feasibility of sport climbing in PD patients in a single-centre, randomised controlled, semi-blind trial. A total of 48 PD patients without experience in climbing (average age 64 ± 8 years, Hoehn & Yahr stage 2-3) were assigned either to participate in a 12-week sport climbing course (SC) or to attend an unsupervised physical training group (UT). The primary outcome was the improvement of symptoms on the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III). Sport climbing was associated with a significant reduction of the MDS-UPDRS-III (-12.9 points; 95% CI -15.9 to -9.8), while no significant improvement was to be found in the UT (-3.0 points; 95% CI -6.0 to 0.1). Bradykinesia, rigidity and tremor subscales significantly improved in SC, but not in the unsupervised control group. In terms of feasibility, the study showed a 99% adherence of participants to climbing sessions and a drop-out rate of only 8%. No adverse events occurred. This trial provides class III evidence that sport climbing is highly effective and feasible in mildly to moderately affected PD patients.

Neurobehavioral Effects of LSVT® LOUD on Auditory-Vocal Integration in Parkinson's Disease: A Preliminary Study

Individuals with Parkinson's disease (PD) are impaired in auditory-vocal integration, characterized by abnormal compensatory responses to auditory feedback errors during self-monitoring of vocal production. The present study examined whether auditory feedback control of vocal pitch production in PD can benefit from Lee Silverman voice treatment (LSVT® LOUD), a high effort, intensive speech treatment for hypokinetic dysarthria in PD. Before and immediately after LSVT LOUD, 12 individuals with PD were instructed to produce sustained vowel sounds while hearing their voice unexpectedly pitch-shifted by -200 cents. Their vocal responses and event-related potentials (ERPs) to pitch perturbations were measured to assess the treatment outcomes. A group of 12 healthy controls were one-to-one pair matched by age, sex, and language. Individuals with PD exhibited abnormally enhanced vocal and ERP P2 responses to pitch perturbations relative to healthy controls. Successful treatment with LSVT LOUD, however, led to significantly smaller and faster vocal compensations that were accompanied by significantly larger P2 responses. Moreover, improved vocal loudness during passage reading was significantly correlated with reduced vocal compensations for pitch perturbations. These preliminary findings provide the first neurobehavioral evidence for beneficial effects of LSVT LOUD on impaired auditory-vocal integration associated with PD, which may be related to improved laryngeal motor functions and a top-down modulation of the speech motor network by LSVT LOUD.

Effects of Lee Silverman Voice Treatment BIG and conventional physiotherapy on non-motor and motor symptoms in Parkinson's disease: a randomized controlled study comparing three exercise models

Background:

Parkinson’s disease (PD) patients experience disabling motor dysfunctions as well as non-motor symptoms (NMSs) that can highly impact their perceived quality of life. Besides pharmacological treatment options, active intervention programs have set some attention in managing these symptoms. However, previous studies mainly assessed the effectiveness of active intervention programs on functional mobility and motor symptoms.

Objective:

This study aimed to investigate the effect of Lee Silverman Voice Treatment (LSVT) BIG, an intensified and personalized physiotherapy (INTENSIVE), and a conventional physiotherapy (NORMAL) on NMSs in PD.

Method:

Forty-four patients with mild to moderate PD were randomly assigned to one of the three treatment groups. LSVT BIG and INTENSIVE were delivered one-on-one in 16 1-hour sessions within 4 weeks (4×/week). Patients assigned to NORMAL received 16 individual 1-hour sessions within 8 weeks (2×/week). The primary outcome measure was the difference in change from baseline in the non-motor symptom assessment scale for Parkinson’s disease (NMSS) between treatment groups to follow up at week 8. Patients were blinded for the NMSS being the primary outcome, but not the different treatment groups.

Results:

ANCOVA (Analysis of Covariance) showed reduced NMSS scores for all groups, with INTENSIVE being superior to NORMAL (p = 0.033). For secondary outcome measures (stride length, gait velocity and chair rising test) LSVT BIG and INTENSIVE were both superior to NORMAL.

Conclusions:

The study provides evidence that all three exercise programs are effective techniques to improve NMSs as well as motor function in PD.

DRKS registration number:

DRKS00008732

Table tennis for patients with Parkinson's disease: A single-center, prospective pilot study

INTRODUCTION

Table tennis is a popular sport worldwide. However, no study has examined whether it is an effective exercise for patients with Parkinson's disease (PD). The efficacy and safety of table tennis exercise for PD patients was examined.

METHODS

This 6-month prospective study investigated if our table tennis exercise program could improve parkinsonian motor symptoms, cognition and psychiatric symptoms. Twelve PD patients with Hoehn & Yahr stage ≤4 were recruited. Patients participated in a 6-hour exercise session once weekly. All patients were assessed with the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) parts I-IV, Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), Self-Rating Depression Scale (SDS), and Starkstein Apathy Scale (SAS) at baseline, 3 months, and 6 months.

RESULTS

Nine of 12 PD patients were analyzed, except for three patients for which data was missing. MDS-UPDRS parts II and III were improved at 3 months (median -4.0, p = 0.012 and median -10.0, p = 0.012) and 6 months (median -7.0, p = 0.015 and median -12.0, p = 0.008), whereas MDS-UPDRS total parts I scores and total IV scores, MoCA, FAB, SDS, and SAS were unchanged. Adverse events included fall and backache in one patient each.

CONCLUSION

A table tennis exercise program is relatively safe and may improve activities of daily living and motor symptoms in patients with PD.

Four-Repeat Tauopathies: Current Management and Future Treatments

Four-repeat tauopathies are a neurodegenerative disease characterized by brain parenchymal accumulation of a specific isoform of the protein tau, which gives rise to a wide breadth of clinical syndromes encompassing diverse symptomatology, with the most common syndromes being progressive supranuclear palsy-Richardson's and corticobasal syndrome. Despite the lack of effective disease-modifying therapies, targeted treatment of symptoms can improve quality of life for patients with 4-repeat tauopathies. However, managing these symptoms can be a daunting task, even for those familiar with the diseases, as they span motor, sensory, cognitive, affective, autonomic, and behavioral domains. This review describes current approaches to symptomatic management of common clinical symptoms in 4-repeat tauopathies with a focus on practical patient management, including pharmacologic and nonpharmacologic strategies, and concludes with a discussion of the history and future of disease-modifying therapeutics and clinical trials in this population.

Lee Silverman Voice Treatment for dysarthria in patients with Parkinson's disease: a systematic review and meta-analysis

Approximately 89% of patients with Parkinson's disease (PD) suffer from dysarthria. Lee Silverman Voice Treatment (LSVT), a behavioral therapy, aims to improve speech and voice functions. The objective was to assess the effectiveness of LSVT compared with other/no speech interventions for dysarthria in patients with PD. Electronic databases, including PubMed, Embase and the Cochrane Library, were searched. The publication date of all included studies was before 6 March 2020. Only randomized controlled trials (RCTs) that evaluated the LSVT intervention compared with other/no speech intervention were considered. The data obtained from the included studies were described and the mean differences were calculated. Eight RCTs were included in this meta-analysis comparing LSVT with other/no speech interventions. In the comparison of LSVT versus no intervention, vocal intensity for sustained 'Ah' phonation, reading the 'Rainbow passage', monologue and describing a picture increased by 8.87, 4.34, 3.25 and 3.31 dB, respectively, after 1 month of therapy. Compared with the respiratory therapy group, the LSVT group also showed significant improvement in vocal intensity for sustained 'Ah' phonation, reading the 'Rainbow passage' and monologue immediately after treatment (13.39, 6.66 and 3.19 dB). Positive improvement still existed after 24 months. There was no difference in the therapeutic effect between face-to-face and online LSVT. The effectiveness of LSVT for dysarthria in patients with PD was verified in these trials. However, future RCTs with sufficient participants are essential to evaluate the effectiveness of LSVT for dysarthria.

Quantitative clinical assessment of motor function during and following LSVT-BIG® therapy

BACKGROUND

LSVT-BIG® is an intensively delivered, amplitude-oriented exercise therapy reported to improve mobility in individuals with Parkinson's disease (PD). However, questions remain surrounding the efficacy of LSVT-BIG® when compared with similar exercise therapies. Instrumented clinical tests using body-worn sensors can provide a means to objectively monitor patient progression with therapy by quantifying features of motor function, yet research exploring the feasibility of this approach has been limited to date. The aim of this study was to use accelerometer-instrumented clinical tests to quantify features of gait, balance and fine motor control in individuals with PD, in order to examine motor function during and following LSVT-BIG® therapy.

METHODS

Twelve individuals with PD undergoing LSVT-BIG® therapy, eight non-exercising PD controls and 14 healthy controls were recruited to participate in the study. Functional mobility was examined using features derived from accelerometry recorded during five instrumented clinical tests: 10 m walk, Timed-Up-and-Go, Sit-to-Stand, quiet stance, and finger tapping. PD subjects undergoing therapy were assessed before, each week during, and up to 13 weeks following LSVT-BIG®.

RESULTS

Accelerometry data captured significant improvements in 10 m walk and Timed-Up-and-Go times with LSVT-BIG® (p <  0.001), accompanied by increased stride length. Temporal features of the gait cycle were significantly lower following therapy, though no change was observed with measures of asymmetry or stride variance. The total number of Sit-to-Stand transitions significantly increased with LSVT-BIG® (p <  0.001), corresponding to a significant reduction of time spent in each phase of the Sit-to-Stand cycle. No change in measures related to postural or fine motor control was observed with LSVT-BIG®. PD subjects undergoing LSVT-BIG® showed significant improvements in 10 m walk (p <  0.001) and Timed-Up-and-Go times (p = 0.004) over a four-week period when compared to non-exercising PD controls, who showed no week-to-week improvement in any task examined.

CONCLUSIONS

This study demonstrates the potential for wearable sensors to objectively quantify changes in motor function in response to therapeutic exercise interventions in PD. The observed improvements in accelerometer-derived features provide support for instrumenting gait and sit-to-stand tasks, and demonstrate a rescaling of the speed-amplitude relationship during gait in PD following LSVT-BIG®.

Outcomes Following LSVT BIG in a Person With Idiopathic Normal Pressure Hydrocephalus: A Case Report

BACKGROUND AND PURPOSE

There is no literature exploring physical therapy interventions for individuals with idiopathic normal pressure hydrocephalus (iNPH). There are parallels between symptoms of iNPH and Parkinson disease (PD), suggesting that similar interventions may be beneficial. An approach that promotes recalibration of movements to produce bigger motions (Lee Silverman Voice Treatment BIG [LSVT BIG]) is an evidence-based intervention for individuals with PD, which could potentially improve function in individuals with iNPH. This case report documents functional outcomes of LSVT BIG in an individual with iNPH.

CASE DESCRIPTION

The participant was a 62-year-old man with a 16-year history of iNPH. He demonstrated hypokinesia, impaired balance, and cognitive deficits. These resulted in frequent falls and limited community ambulation.

INTERVENTION

The participant completed the standardized 4-week LSVT BIG program in addition to 5 tune-up sessions 7 months later. Outcome measures included the Berg Balance Scale (BBS), Timed Up and Go (TUG), TUG cognitive and manual, Activities-Specific Balance and Confidence (ABC) scale, Five Times Sit to Stand (5TSTS) test, and a timed floor transfer.

OUTCOMES

Improvements, exceeding minimal detectable change values, were noted on the BBS and the ABC scale immediately following intervention. Scores declined at 4-month follow-up, but BBS scores increased again after the tune-up sessions. Quicker floor transfer times were also noted. There were no changes in TUG, TUG cognitive and manual, or 5TSTS times.

DISCUSSION

Therapists may wish to consider the use of the LSVT BIG program in persons with iNPH; however, a longer program and/or regular tune-up sessions may be necessary for best outcomes.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A315).

Use of Occupation-Based Measures in LSVT BIG Research: A Case Study

Parkinson's disease (PD) is a neurodegenerative disorder that results in a variety of motor and nonmotor symptoms that impact occupational performance. To our knowledge, no study has investigated the effect of LSVT BIG using occupational performance outcome measures. The objective of this study was to determine the effects of LSVT BIG on occupational performance with an individual with PD. The participant, a 73-year-old retired female with mild PD, completed the LSVT BIG program. Researchers measured changes in occupational performance using the Canadian Occupational Performance Measure (COPM) and the Performance Assessment of Self-Care Skills (PASS). Results indicated improved client perceptions of occupational performance and satisfaction on the COPM and improved independence and adequacy on the PASS. Despite the positive findings of this study that support the use occupational performance measures to evaluate change within LSVT BIG literature, future research should be conducted to determine causality of identified occupational performance improvements and time course of improvements.

Development of a community-based golf and exercise program for people with Parkinson's disease

Individuals with Parkinson's disease (PD) typically display symptoms of rigidity, bradykinesia, and postural instability that can limit participation in recreational activities. The purpose of this clinical report is to describe the development, implementation, and outcomes of a novel and innovative community-based golf and exercise program for individuals with PD. In response to community interest, the program was developed through a unique partnership that blended the expertise of physical therapists and golf professionals. The 6-week program consisted of golf instruction and task-specific exercises. Improvements were noted in seven of eight participants for golf performance (driving distance and club head speed) and quality of life (PD Questionnaire-39) outcome measures. This report describes the design and implementation of a golf and exercise program for people with PD based on community need, evidence, and clinical expertise. Considerations and recommendations for future programs are discussed, such as program length, staffing, volunteers, funding, location, and resources.