Physical Therapy EBP 2016

Introduction:

• Physical Manifestations such as hypokinetic movements can lead to an increased risk of falls in the Parkinson’s Population. BIG Therapy was created to address this specific limitation.
• LSVT BIG Therapy
  • Training Protocol
    • High amplitude movements performed at high intensity (≥ 8 on RPE)
    • Minimum 4x/wk for 4 weeks with strict HEP
    • Certification needed

Clinical Case & PICO Question:

• Eileen is a 65 y/o female with a PMH of Idiopathic Parkinson’s Disease dx 11yrs, pt rated 3 on Hoehn and Yahr Scale, R humeral Fx 2 months ago secondary to fall. Meds include Siminet 4x/d & ASA as necessary.
• Impairments on eval: Frequent faller (6 times in the last year), Diminished stride length, Freezing gait when turning
• PICO: Can targeting the hypokinetic movements through BIG Therapy reduce the risk of falls in individuals with PD as opposed to traditional therapy techniques?

Search Strategy:

• 3 Databases: PubMed, CINAHL, PEDro
  • Search Terms: BIG therapy AND Parkinson’s Disease AND Parkinson’s Disease AND Physical Therapy AND Falls
  • Inclusion Criteria: English, Full text, Humans, Adults >18, Idiopathic PD <5 on H&Y scale, minimum dosage of 1 therapy session per week for a minimum of 4 weeks, Used TUG as a primary or secondary outcome measure.

Results: Studies in Red involve BIG Therapy, Studies in white are traditional therapy.

Limitations:

Small sample sizes, lacking of blinding of patients and therapists, unable to generalize results to entirety of Parkinson’s population, ceiling effect of outcome measure chosen

Clinical Bottom Line:

Level 2 and 4 evidence exists that suggests LSVT BIG Therapy can help improve motor functions that assist in the decrease of falls risk in PD populations. Level 2 evidence also exists that demonstrates a direct decrease in falls for those participating in traditional therapy that focuses on resistance and/or balance training in individual or group settings. At this time, more research is required to determine whether LSVT BIG Therapy has a direct correlation to reduction in falls risks. Another important area to focus is whether the intensity of an exercise program can effect a patient’s fall risk.

Application:

Based on the evidence provided the best treatment method for Eileen at this time would be to participate in traditional strength and balance training with principles of BIG therapy included throughout.

BIG Therapy limitations: Cost, Time, UE involvement

Recommended Program:
Sessions 2-3x/wk for ~1hr: Primary treatment of UE ROM
Repeated functional movements: Sit-to-stand, lunging (all directions), bed mobility. Progress: supported to unsupported
Balance training: Reactive, Anticipatory, Sensory Integration
Progressive bodyweight activities including: Squats, H/T raises, BIG walking
Key Factor: All activities performed at RPE ≥ 7 – resting when needed

References:

1. Ebersbach G, Ebersbach A, Edler D, et al. Comparing exercise in Parkinson’s Disease – the berlin LSVT BIG study. Movement Disorders. 2010;25(12):1902-1908.

2. Goodwin V, Richards S, Henley W, Exings P, Taylor A, Campbell J. An exercise intervention to prevent falls in people with parkinson’s disease: A pragmatic randomized controlled trial. J Neurol Neurosurg Psychiatry. 2011;82:1232-1238.

3. Ebersbach G, Ebersbach A, Grust U, Wegner B, Gandor F, Kuhn A. Amplitude-oriented exercise in parkinson’s disease: A randomized study comparing LSVT-BIG and a short training protocol. J Neural Transm. 2015;122:253-256.

4. Janssens J, Malfroid K, Nyffeler T, Bohlhalter S, Vanbellingen T. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with parkinson disease: A case series.Phys Ther. 2014;94(7):1014-1023. doi: 10.2522/ptj.20130232 [doi]

5. Morris M, Menz H, McGinley J, et al. A randomized controlled trial to reduce falls in people with parkinson’s disease. Neurorehabilitation and Neural Repair. 2015;29(8):777-785