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Melanie Cole, MS (Host): Way back in the day when I used to work with people with Parkinson’s disease, we knew that exercise was good for them and made them feel better, and even helped them with their gait. But we didn’t have so many tools in our tool box as they have now. While the times have really changed, we’re talking today with Emily Devine and Rachel Peerenboom. They're physical therapists with Stoughton Hospital. Emily, let’s start with you. You’ve been on with us before to talk about Parkinson’s. Tell us a little bit, some of the effects of living with Parkinson’s. What happens with neurological conditions, such as this, in regards to their movement.

Emily Devine, DPT (Guest): With regards to Parkinson’s, it can effect people fairly differently. As you mentioned, it’s a neurological condition. But generally, it kind of makes people’s gestures and actions become smaller and slower. So that’s kind of that classic type of walking that you may see on friends or family where it’s more of a shuffling or little short steps kind of gait. Small, slowness of movements. Sometimes tremors. So it can vary based on the person, but those are just kind of some of the general symptoms.

Host: Rachel, you're a physical therapist. As I said in the beginning, I'm an exercise physiologist. I used to work with Parkinson’s patients, and we saw how exercise helped them. How can physical therapy and exercise and some of the new tools that you have help ease tremors and some of that rigidity that Emily mentioned?

Rachel Peerenboom, DPT (Guest): Yeah. So with more of the structured exercise with a physical therapist can improve bigger steps with their walking, improve their arm swing. As Emily mentioned, some of the classic symptoms, the arm swing tends to be a little bit less in patients with Parkinson’s. So doing the exercises definitely help with that. Decreasing falls risk, improving bed mobility. Both gross motor and more of the fine motor movements, like buttoning the shirt, those things can really be improved with more of the exercise.

Host: See, I don’t think we knew that 20/30 years ago really. Now there’s a program called LSVT. It has big and loud. So, Emily, tell us just about the program LSVT. What does it seek to accomplish?

Emily: Sure. So LSVT stands for Lee Silverman Voice Training. It originated in the mid to late 80’s. Initially working with people that had Parkinson’s and were really effected with their voice or their speech. That’s where we hear the term LSVT loud. With that, they found that with patients getting some really good results, they then kind of got this into more of a physical therapy or more of a gross motor activity. That’s where we hear now LSVT big. Now with LSVT big, it is a customized program that really looks at patient’s specific needs and really can tackle their specific goals. It’s four times a week for one hour for 16 visits, of for a whole month. So it’s a pretty intense program where it really focuses on amplitude of movement, or that bigness of movement. It’s a high intensity, high effort kind of activity with the ultimate goal to kind of—They use the word calibrate—or make people’s movements now become more normal with regards to how they’re moving.

Host: Rachel, expand on that a little. When she says big, what does that mean as far as the movements that you're teaching patients?

Rachel:  Yeah. So with every patient that we see, there’s a standardized group of exercises that has been very research based that has come out of the program. So every person that we see goes through those particular exercises, but it’s very individualized to the person. So if somebody has a little bit more difficulty, they may need balance assistance or doing them sitting down instead of standing. We can go that route. Or for somebody who actually functions fairly well, we can make it as challenging as it needs to be. So it’s really kind of up to the patient’s and how they're moving to kind of determine what type of progression we can do for them.

Then in addition to those standard exercises, there’s groups of exercises called functional component tasks where a patient can decide their top five things that they're having difficulty with, which is where the individualization comes in. So whether it’s standing from a chair or rolling over in bed, really anything that they're having difficulty with we can work on with the program.

Host: Emily, again, just going back to the big thing because I think people don’t really understand what that means. When you're making these movements that Rachel just described, whether it’s rolling over in bed or getting up from a chair, how does that word big even come into this? How does a movement become big?

Emily: Yeah. That’s a great question. I think the first thing we have to do is realize a Parkinson’s perspective. Somebody that has Parkinson’s disease, generally their world is smaller in the sense that they’re not maybe reaching their arm as big over their head to put a short on as they need to to make that a successful task. That slowness of movement is called bradykinesia or hypokinesia is a lack of movement there. When we talk about big, what we’re trying to do is teach that person that even though they may feel like they’re moving their arm appropriately to get that arm all the way through their shirt or their jacket that they need to go a little bit more amplitude or put more power behind it. That’s where that intensity and high effort kind of comes into play.

Now also with regards to Parkinson’s disease, those patients really respond well to those external cues. Those can be things like a metronome on a cellphone to help with taking bigger steps for walking. It could be your voice saying the word big to take bigger steps for walking or a bigger movement with your arm to put that shirt on. So it really is kind of just depending, like Rachel said, on what that task is that that individual wants to work on and taking that task and kind of breaking it down into those little simple parts and teaching that person how to kind of, I guess be bigger for lack of a better word. That’s where that intensity and that high effort and then that consistent—four times a week for four hours total for a week for a total of 16 visits. So one hour, four times a week for a total of 16 visits. They consistently work on that program that Rachel mentioned where they do these maximal daily exercises, and then they get those functional components sort of really kind of customized to that patient. They work on those consistently over the next four weeks, which they ultimately do get some really good results.

Rachel: I would kind of echo with what Emily said too in the fact that the patient with Parkinson’s feels like they’re moving big when, in fact, to the outside person, they're not. So the whole point of the big program is getting them to move what we see as more normal, but to them might feel big at first. Just trying to recalibrate how they feel they are moving.

Host: Isn’t that interesting? To expand those movements to what they think would be over and above or bigger, but to us it’s more of a normal movement. Rachel, as Emily said that it’s a pretty intense program, how long does it take to see results? What have you heard from Parkinson’s patients about participating in a program like this?

Rachel: Yeah. So for the results piece, obviously everyone’s very different, but I would say after the first week to two weeks we start to notice just those subtle changes. Even family members will say, “Wow. I really feel like this person is starting to take bigger steps, or I really notice that they're getting out of the car a little bit easier than they were.” I would say definitely by the end of the program, we really hammer to the bigness of that movement. We say it probably a million times during their treatment sessions. So they really get used to just carrying that over to home too.

Emily: I will also say that a lot of times when we talk about the intensity of the program, meaning you have to come to clinic for one hour a day for four days a week for 16 visits, or for four weeks. I think sometimes that can be a really intimidating amount of time for patients that have Parkinson’s disease. What I feel I consistently hear from those patients is one, how quickly it goes, and once they kind of get into that, they just get those benefits like Rachel said. You just see little by little those improvements. That can be really motivating for folks. But they just got to get that foot in the door and get started and try to make that commitment to the program, and they’re really gonna end up with some great outcomes in the end.

Rachel: I think once patients start, it kind of keeps them accountable too to see them four times a week. That we’re asking them did you do your home exercise program last night? Are you keeping up with the extra things that we ask you to do? So it kind of keeps that accountability point too.

Host: See, I think that that’s great and that’s one of the great things about the program is that accountability and the fact that family members are seeing these results and noticing them. Emily, what does a patient have to do at home? That segues great into how does the follow up for this type of a program and what do you want them working on when they're at home? Can their loved noes get in on the session to see what it is you guys are doing?

Emily: Yeah. That’s a great question. So with regards to the program, the patients participate on a maximal daily exercise program that is different movements and stretches that are consistent throughout the entire session that they're going to be doing. Then they also will have little components and functional tasks as well as daily carryover assignments. Those are done twice a day, with the exception of if they are in therapy that day. That counts as one. We encourage family members to participate with them. Not only just to have a little more fun doing the exercises and embrace that together because movement’s good for everyone, but that modeling that the patient’s loved one or caregiver can do. Meaning them doing the exercises is a great external cue for that patient to improve their movements even more. So if they can do it with a family member, even better in my opinion. It kind of benefits both.

Rachel: To going along with that too, there are videos that you can purchase through the LSVT websites. So if the patient maybe doesn’t have a caregiver or if someone’s just not able to participate with them at home, there’s a video that they can watch. It kind of goes and walks them through all the exercises that they should be doing at home too.

Host: Now that’s pretty good. Now Rachel, you're a physical therapist. Emily is a physical therapist. Is there a special certification to teach the LSVT program?

Rachel: There is. So the certification, I personally did mine online. I did it with a group of other physical and occupational therapists. So we did ours online to get our certification. It took us about a week or so, a few hours each day. But there’s also in-person training courses that someone can attend also to get that certification.

Host: Then let’s start Rachel with you. What would you like listeners to take from this segment as far as this LSVT program and Parkinson’s and the benefits? What do you want them to know?

Rachel: Yeah, great question. So I would say, as Emily mentioned before, I think the program can be very intimidating to see all of the amount of sessions that someone has to go through. I think once you get started, we make it as fun as it can be. We’re both very lively people. So we get patients involved, family members involved. I think just getting that foot in the door, like Emily said to get that program started and just get that person too just can really change the way they move. It just makes things a little bit more easy for them to move throughout the day and do the daily things that they want to incorporate in their life.

Host: Emily tell us, as you wrap up, what would you like listeners to know about getting involved? And just in general about Parkinson’s and kind of the feeling of what you see going on in the future and on the horizon for Parkinson’s patients.

Emily: Well, I think the big take home message for people that do have Parkinson’s disease is to realize that exercise does help. So whether you engage in daily exercise on your own or you chose to do a program like Rachel and I are speaking about about LSVT big, that’s the first step. Take that step forward and try to get your body moving better. The benefit of LSVT big is that it’s that one on one tailored time with a specialist that can really focus on your unique needs and help improve your abilities and reach those goals that you’ve been struggling with. I think the more research that comes out, it’s showing how important that exercise is. It’s not just medicine that helps with regards to Parkinson’s. It kind of gives you that holistic approach when you can get out and do some exercise with friends, family, or using videos and just get moving and kind of take back some of that movement on your own.

Rachel: So going along with that too, I would say the earlier that someone gets that diagnosis, they're starting to show symptoms. The earlier they start moving and start exercising, like Emily said, no matter if it’s on their own or with us or with another physical therapist the better. But we see people throughout a very wide range of abilities. So even if you may be later in your diagnosis, there’s still benefits to exercise too.

Host: What a great ending. You both, I can hear the passion in your voices. I'm sure that patients really love to work with you. What a great program. Thank you so much for being with us today and explaining LSVT bug. This is Stoughton Hospital Health talk. For more information on the LSVT big program at Stoughton Hospital, please visit stoughtonhospital.com. That’s stoughtonhospital.com. I'm Melanie Cole. Thanks for tuning in.