Webinar Presenters. LSVT BIG : Evidence-Based Physical and Occupational Therapy for Parkinson s Disease. Plan for Webinar 1/25/2016

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1 LSVT : Evidence-Based Physical and Occupational Therapy for Parkinson s Disease Supported, in part by research grants: R01 DC01150, R21 RFA-NS , R21 DC006078, R21 NS Plan for Webinar Logistics Brief Review Resources and Opportunities Address your questions Webinar Presenters Heather Cianci, PT, MS, GCS LSVT Training and Certification Faculty Beth Marcoux, DPT, PhD LSVT Training and Certification Faculty Global, Inc

2 Instructor Biographies Heather Cianci, PT, MS, GCS Ms. Cianci is the founding therapist of the Dan Aaron Parkinson's Rehab Center (a Good Shepherd Penn Partners facility) at Pennsylvania Hospital in Philadelphia, PA. She received her bachelor's in PT from the University of Scranton in Scranton, PA and her master's in gerontology from Saint Joseph's University in Philadelphia. Heather received her GCS in She is certified in LSVT and is a graduate of the NPF's Allied Team Training for PD. She has written and lectured for both the NPF and PDF. Heather is also a board member for CurePSP, and the coordinator of their Medical Professionals Advisory Committee. Beth Marcoux, DPT, PhD Dr. Marcoux holds a BS in Physical Therapy from Russell Sage College, an advanced Master s degree in Physical Therapy Education from the University of Alabama, Birmingham, a Ph.D. in Public Health (Health Behavior and Health Education) from the University of Michigan and a Doctor of Physical Therapy from the Massachusetts General Hospital Institute for Health Professions. She has served on physical therapy faculties at the University of Vermont, the University of Michigan, and University of Michigan-Flint, Henry Ford Community, Oakland University and the University of Rhode Island where she was Professor and Chair of Physical Therapy for seven years. She is certified in LSVT and for the past 5 years her clinical experience has focused on the treatment of patients with Parkinson s disease. Objectives of Presentation Briefly explain advances in neuroscience and impact on the field of rehabilitation Discuss development and data on an efficacious speech treatment LSVT LOUD Describe development, data and exercises of LSVT Learn how clinicians in the UK can become LSVT Certified in 2016 It is a Stunning Time to be in rehabilitation today Basic science evidence for the value of exercise in PD (classically drugs, surgery, today ) Identified key principles of exercise that drive activity-dependent neural plasticity Demonstrated that exercise can improve brain functioning (neural plasticity) and may slow disease progression Exercise is Medicine! Kleim & Jones, 2008; Ludlow et al, 2008 Global, Inc

3 Rehabilitation (ST, PT, OT) is becoming a routine part of management in PD To provide symptomatic relief; improve function Pharmacological (L-dopa) Neurosurgical (DBS-STN) Speech, Physical Occupational Tx (Empower) Kleim & Jones, 2008; Kleim et al., 2003; Zigmond et al, 2009 Patient case: Bernie 71 year-old, diagnosed with Parkinson s disease in 1994 Reason for referral: slowness and difficulty walking, history of falls, freezing Optimized on PD medications Hoehn & Yahr 3 LSVT pre and post treatment video Global, Inc

4 Case Study Outcomes: PRE POST Falls 1-2/month 0/month Assistive device Cane None Gait Velocity 0.35 m/s 1.17 m/s % of age matched norm 29.6 % 100% Endurance 730 ft 1200 ft To improve his walking To go to the movies To play with his grandchildren To go out to dinner with friends and family Where did we begin If only we can hear and understand her Family of Mrs. Lee Silverman 1987 Global, Inc

5 25+ year journey from invention to scale-up Over 8 million dollars in NIH funding Phase I, II Phase III Phase IV, V : Initial invention; Pilot data (Scottsdale) : Office of Education OE-NIDRR : OE-NIDRR : NIH funded RCT Efficacy : NIH funded EMG, Kinematics : NIH funded RCT Spread of effects : NIH funded RCT, imaging : Coleman Institute (PDA; LSVTC) : NIH and M J FOX Foundation PDA (R21) : Coleman Institute (VT; LSVTVT) : NIH LSVTVT (R21) 2004 : Coleman Institute (LSVT Down Syndrome) : LSVT Dissemination 2006: Technology-enhanced Clinician Training (SBIR) 2010: Technology-enhanced LSVT LOUD delivery (SBIR) LSVT LOUD global standard for Speech Treatment for PD (Pinto et al., 2004) NICE Great Britain Over 16,000 LSVT LOUD Certified Clinicians in 69 countries Over 10,000 LSVT Certified Clinicians in 38 countries Data as of January, 2016 People with PD in the UK need you! 273 LSVT LOUD Clinicians Only 17 LSVT Clinicians! Over 125,000 people in the UK have PD! Global, Inc

6 LSVT Programs Administered in an intensive manner to to challenge the impaired system. Techniques specific to PD-specific deficits! bradykinesia/hypokinesia and kinesthetic awareness (sensory deficit) TARGET Loud is more than a laryngeal event spread of effects LOUD SOFT HEALTHY LOUDNESS MODE What are the LSVT LOUD exercises? Daily tasks First half of treatment session Rescale amplitude of motor output through CORE Loud Sustained ah (minimum15 reps) High/Low ah (minimum15 reps) Functional phrases (minimum 50 reps) Hierarchical speech tasks Second half of session Train amplitude from CORE exercises into in context specific and variable speaking activities Week 1 words, phrases Shorter, simple Week 2 sentences Week 3 reading Week 4 - conversation Longer, more complex Global, Inc

7 CALIBRATION MISMATCH between on-line perception of output and how others perceive it I m not too soft I can t speak like this, I am shouting!! Fox et al, 2002; Sapir et al, 2011 Established Clinical Efficacy Ramig et al., 2001; JNNP Level 1 Evidence Goetz, N=45 SPL Rainbow (50 cm) RESP & VOICE (LSVT LOUD) RESP Months Blinded, no med change Same time med LSVT R Strobe (Smith) EMG Advances in Clinical Efficacy (Ramig et al, 1995; 1996; 2001a; 2001b; Goetz, 2003) Cross-system effects, Neural changes P. Fox, Liotti (2003) Narayana (2010) (PET) Spielman, Borod (2003) (facial expression) Dromey, (1995) (articulation) El-Sharkawi, Logemann (2002) (swallowing) Smith, M. (1995) (adduction) Ramig & Dromey (1996) (aerodynamics) Sapir (2007; 2010) (articulatory acoustics) Smith,A. (2001) (STI) Huber, Stathopoulos, (2003) (respiratory kinematics) Taskoff (2001) (perceptual) Baker (1998), Luschei (1999) (EMG) Global, Inc

8 LSVT LOUD LSVT (Ebersbach et al, 2010; Farley & Koshland, 2005; Fox, et al., 2012) What are the fundamentals of LSVT? Standardized, research-based, specific protocol TARGET: Bigness (amplitude) MODE: Intensive and High Effort CALIBRATION: Generalization Sensory Internal cueing Neuropsychological changes TARGET (Large amplitude whole body movement) Single Target - Triggers Activation across motor systems SMALL Global, Inc

9 MODE Delivery Certified LSVT Physical/Occupational Therapist 1:1 intervention Time of Practice 4 consecutive days per week for 4 weeks 16 sessions in one month 60 minute sessions Daily carryover assignments (30 days/entire month) Daily homework (30 days/entire month) Why? Less intensive PT and OT may be ineffective! Intensity is a key parameter of driving activity dependent neuroplasticity Intensive, repetitive practice is needed in PD due to underlying non-motor symptoms that interfere with learning and improvement of motor symptoms Clark et al, JAMA Neurol 2016, Kleim and Jones 2008 CALIBRATION MISMATCH between on-line perception of output and how others perceive it I had no idea how small my world had become I can t move like this, people will think I am crazy!! Global, Inc

10 PRE-TREATMENT Problem in self-perception/awareness - do not recognize movements are small or slow Self-cueing deficits - continue scaling reduced amplitude of movement patterns Produce slow, small movements Reduced amplitude of motor output Fox et al., 2012 TREATMENT FOCUS Improve self-perception/awareness of amplitude required to produce normal movement amplitude Improve self-cueing/attention to action - habitually scale increased amplitude of movement patterns Produce larger movements INCREASE amplitude of motor output Fox et al., 2012 LSVT : Data Global, Inc

Comparing Exercise in Parkinson s Disease The Berlin LSVT Study (2010, Movement Disorders) Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1 Andreas Kupsch,2 and

11 Comparing Exercise in Parkinson s Disease The Berlin LSVT Study (2010, Movement Disorders) Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1 Andreas Kupsch,2 and Jo rg Wissel 3 Comparing Exercise in Parkinson s Disease The Berlin LSVT Study (2010, Movement Disorders) Georg Ebersbach,1* Almut Ebersbach,1 Daniela Edler,1 Olaf Kaufhold,1 Matthias Kusch,1 Andreas Kupsch,2 and Jo rg Wissel 3 FIG. 2. UPDRS motor score (blinded rating), mean change from baseline (vertical bars 5 standard deviations). Change between baseline and follow up at week 16 was superior in (interrupted line) compared to WALK (dotted line) and HOME (solid line), P < ANCOVA did not disclose significant differences between in intermediate and final assessments. What about Fine Motor Tasks? Even small movements are TOO SMALL in people with PD! Examples: writing, buttoning, teeth brushing, stirring Global, Inc

12 Short Buttoning Video Initial 3/15/2010 Discharge 4/8/2010 Generalized Amplitude: Uncued writing post-treatment and untrained during therapy LSVT : Treatment Protocol Global, Inc

OVERVIEW PROTOCOL 4 consecutive days a week for 4 weeks 16 sessions in 1 month 60 minute sessions LSVT Treatment Session Maximal Daily Exercises 1.Floor to Ceiling 8 reps 2.Side to Side 8 each side 3.

13 OVERVIEW PROTOCOL 4 consecutive days a week for 4 weeks 16 sessions in 1 month 60 minute sessions LSVT Treatment Session Maximal Daily Exercises 1.Floor to Ceiling 8 reps 2.Side to Side 8 each side 3.Forward step 8 each side 4.Sideways step 8 each side 5.Backward step 8 each side 6.Forward Rock and Reach 10 each side (working up to 20) 7.Sideways Rock and Reach 10 each side (working up to 20) Functional Component Tasks 5 EVERYDAY TASKS 5 reps each For example: -Sit-to-Stand -Pulling keys out of pocket -Opening cell phone (flip phone) Hierarchy Tasks Patient identified tasks: Getting out of bed Playing golf In and out of a car Build complexity across 4 weeks of treatment towards long-term goal Walking Distance/time may vary Maximum Sustained Movements Floor to Ceiling Global, Inc

Reach Forward Step Reach Sideways Step Global,

14 Maximum Sustained Movements Side to Side Multidirectional Repetitive Movements Step and Reach Forward Step Multidirectional Repetitive Movements Step and Reach Sideways Step Global, Inc

15 Multidirectional Repetitive Movements Step and Reach Backward Step Multidirectional Repetitive Movements Rock and Reach Forward/Backward Rock and Reach Multidirectional Repetitive Movements Rock and Reach Sideways Rock and Reach Global, Inc

facilitate improved movements, not the end

bed Sit to stand Sit & reach Stand & reach

16 -Stepping stones for use of good big movements in daily life- -Tools to facilitate improved movements, not the end goal of therapy- Functional Component TASKS Functional Components Patient DRIVEN! Rolling Floor to Stand Getting in or out of bed Sit to stand Sit & reach Stand & reach Walk & reach Walk & turn Stand & turn Sit to stand Global, Inc

Tennis Chores Golf Hiking Gardening Getting

train/bus/car Getting the mail Cleaning the

17 Mental Sticky Notes- Think!!! Hierarchy Task Examples Real-World Tasks Patient DRIVEN! In/Out of Car Walk and Talk ADL s Writing Tennis Chores Golf Hiking Gardening Getting in/out of bed Laundry Going out to church/restaurant Playing with children/grandchildren Shopping Transportation: train/bus/car Getting the mail Cleaning the house Example of Subtasks Preparing a Meal Retrieve Ingredients Gather tools, Prepare Food Stir or Put in Oven, Etc. Serve Food Global, Inc

18 Hierarchy Considerations Calibration (Our Goal!) Patient self-critiques they are engaged in sensory processing/problem solving Did you use high effort/bigness To get out of the chair? Walking - Big arm swings, Big steps - This may feel awkward at first, if it doesn't, it is probably not enough! Normalize amplitude, stride length posture, arm swing overtime. Carryover Exercises Daily assignments to use Big movements in real life situations outside of the treatment room Difficulty of the assignment progresses across the four weeks of treatment Carryover exercises are specific and you are made accountable for doing them Global, Inc

19 LSVT Carryover Examples Week 1 Example: When you leave the clinic, walk to your car with your spouse. Walk enough that he/she comments about your walking. Week 3 Example: When you go to the restaurant today with your family, open the door for someone, walk to your table and sit down. Use your posture when you order your meal and sit through dinner. LSVT TREATMENT GOAL People with Parkinson disease will use their bigger movements automatically in everyday living and there will be long-term carryover of increased amplitude use! Summary Advances in neuroscience have provided neurobiological and behavioral evidence supporting the positive impact of exercise-based protocols in people with PD There is a rapidly growing literature in physical therapy/exercise protocols in humans with PD LSVT Programs have been developed and studied over the past 20 years LSVT is one type of physical therapy program that has potential to offer improvements in movement and quality of life for people with PD Global, Inc

20 Resources for LSVT Certified Clinicians and the PD Community Webinars - Clinician and PD Community LSVT Clinician Directory Ask the Expert LSVT and LSVT LOUD Homework Helper DVDs Future Development: LOUD for LIFE and for LIFE How can I become LSVT Certified? Attend our workshop in the UK! Derby (East Midlands), UK March 17-18, 2016 Complete Registration Brochure found at: For more info contact NCORE: Phone: dhft.ncore@nhs.net Website: OR, Take LSVT Training ONLINE! Upcoming LSVT LOUD Workshops London, June 24-25, on-uk-jun loud Invite your SLP colleagues and refer your PD patients to the Day 2 symposium! Global, Inc

LSVT Global at MDS Congress! 20 th International Congress of Parkinson s Disease and Movement Disorders Society Congress June 19-23, 2016 Berlin, Germany http://www.mdscongress2016.org/congress- 2016.

21 LSVT Global at MDS Congress! 20 th International Congress of Parkinson s Disease and Movement Disorders Society Congress June 19-23, 2016 Berlin, Germany htm Come visit us!!! It is possible to take charge of your life, even with Parkinson s. It is possible for your will to override your brain. It is possible to have Power Over Parkinson s ~Sharon Kha LSVT and LSVT LOUD Graduate Thank you! Questions??? info@lsvtglobal.com Global, Inc

7/13/2016. Copyright LSVT Global, Inc Plan for Webinar

7/13/2016. Copyright LSVT Global, Inc Plan for Webinar Freezing in PD: Tricky, Sticky Situations: I m not cold, but my feet want to stick and my words won t come out! Heather Cianci, PT, MS, GCS LSVT BIG Training and Certification Faculty, LSVT Global, Inc.