Overview of Training BIG Program for PD

The BIG Program is a branch of the LSVT (Lee Silverman Voice Treatment) a specialized therapeutic approach designed to address the speech and movement problems faced by individuals with Parkinson's disease. LSVT has two primary branches:

1. LSVT LOUD: This program improves vocal loudness and clarity of speech. It is designed to assist patients in recalibrating their perception of loudness, encouraging them to speak more forcefully and clearly, which can improve communication abilities.

2. LSVT BIG: This branch focuses on physical movement, emphasizing larger and more intentional movements to enhance overall motor function. The program aims to assist patients in increasing the amplitude of their movement, which can improve mobility and reduce the risk of falls. (Fox et al., 2012).

Strength, cardio, flexibility, balance, and memory exercises are all included in the program.

Treatment Protocol

1. Total Session: 16 individual sessions. 2. Duration: one month.

3. Frequency: four sessions per week.

4. Session Length: 60 minutes for each session.

5. With daily carryover and homework exercises.

The Goal of LSVT BIG Training

The Big Training program aims to improve cognitive function, including memory and attention, improve motor function, improve quality of life, slow the progression of disease, and encourage independence. (Eldemir et al., 2024). The following diagram shows the needed effort of an individual with Parkinson’s to approach ‘normal’.

Advantages of LSVT BIG Training

1. Improved Motor Function

(Laura, S. 2023).

Enhancing Larger Movements: LSVT BIG trains patients to execute larger, more intentional movements, counteracting the small, shuffling motions often seen in PD. Emphasizing Enhanced Coordination: The program focuses on coordinated movements, improving overall motor control.

2. Increased Strength

Engaging Muscle Activation: By practicing big movements, patients effectively engage and strengthen their muscles.

Building Functional Strength: Strengthening core and limb muscles aids in daily activities, making tasks easier and safer. 3. Better Balance and Stability

Balance Training: LSVT BIG incorporates exercises that enhance balance, reducing the risk of falls.

Postural Control: Improved posture contributes to better stability during movement.

4. Enhanced Gait

Walking Patterns: The program helps improve stride length and walking speed, making walking more fluid and less effortful.

Reduced Freezing Episodes: Patients often experience fewer freezing episodes, a common symptom of PD.

5. Increased Flexibility

Range of Motion: LSVT BIG exercises promote flexibility, reducing stiffness and enhancing overall mobility.

Joint Health: Maintaining flexibility helps protect joints and prevent discomfort.

6. Cognitive Benefits

Focus and Attention: The program encourages mental engagement in movements, which can enhance cognitive function.

Motor Planning: Practicing larger movements helps improve the brain's ability to plan and execute actions.

Boosted Confidence: As individuals see improvements in their movement and mobility, their confidence in performing daily tasks can increase.

7. Improved Quality of Life

Independence: By enhancing mobility and reducing symptoms, LSVT BIG helps patients maintain independence in daily activities. Emotional Well-being: Physical activity can boost mood and reduce feelings of depression and anxiety.

8. Tailored Approach

Individualized Programs: LSVT BIG is customized to meet each patient's specific needs and abilities.

Supportive Environment: The therapy is conducted in a supportive setting, encouraging patient engagement and progress.

9. Long-term Benefits

Sustained Improvements: Early intervention with LSVT BIG can lead to long-lasting improvements in motor function and quality of life.

Prevention of Decline: Ongoing practice can help prevent or slow the progression of motor symptoms.

10. Increased Awareness of Movement: The training encourages participants to be more aware of their movements, which can lead to better control and execution of tasks.

11. Supportive Environment: The program is typically conducted in a group setting, providing social support and motivation among participants. (Eldemir et al., 2024) (Millage et al., 2017).

How to Implement the Big Training Program for Parkinson’s Disease

The Big Training Program, also known as LSVT BIG, is a structured exercise protocol designed to help individuals with Parkinson’s disease (PD) improve their motor function by emphasizing large, deliberate movements. The core idea of this program is to counteract the slowness, stiffness, and reduced amplitude of movements caused by PD. Below is a detailed guide on how to implement the Big Program effectively. 1. Initial Evaluation and Goal Setting

Before starting the program, a certified LSVT BIG therapist performs a comprehensive assessment of the patient’s physical abilities, including range of motion, walking patterns, balance,

and overall mobility.

Set specific goals: These might include improving walking speed, increasing independence in daily activities, or reducing the risk of falls.

Individualization: The program is tailored to the patient’s needs, as PD symptoms and severity vary widely. (Schenkman et al., 2012).

2. Structure of the Program

The standard LSVT BIG program consists of:

Four sessions per week for four weeks.

Each session lasts 60 minutes, with exercises designed to improve amplitude (bigger movements) and function.

Daily home practice: Patients must also perform exercises at home for 10-15 minutes daily to reinforce what they learn in therapy.

3. Core Components of the Big Training Program

The program consists of a combination of core exercises, functional movements, and task-specific practice.

A. Core BIG Exercises

These exercises focus on large-amplitude, exaggerated movements and are repeated multiple times to improve motor output. Some examples include: 1. Seated or Standing Forward Arm Reaches:

The patient reaches both arms forward with as large a motion as possible, and then returns them slowly to their sides.

(Worsfold et al.,2020).

2. Side Arm Stretches:

The patient stretches both arms out to the sides and holds the position briefly to improve flexibility.

(Nyapong, S. 2021).

3. Step-and-Reach Movements:

Patients step forward with one leg while reaching overhead with both arms to improve balance and coordination.

Instructions

Perform each movement with maximum effort and conscious control. Focus on slow, deliberate actions to maintain form and prevent injury. Each exercise is typically repeated 8-10 times in a session. (Lehman et al., 2005).

(Aguero, F. 2022).

B. Functional Movements Practice

The Big Program integrates exercises with real-life tasks that patients encounter daily. This helps them apply larger movements to improve their functional abilities.

1. Sit-to-Stand Transitions:

Patients exaggerate the motion of standing up from a seated position to build leg strength and improve posture.

2. Walking with Large Steps:

Patients are encouraged to walk with longer strides and deliberate arm swings to reduce shuffling and improve gait.

3. Opening Doors or Reaching for Objects:

The therapist trains patients to use exaggerated arm movements when performing tasks like opening doors or retrieving items from shelves. (Lin et al.,2007).

Instructions Practice these functional movements at least once a day at home to reinforce the learning. Therapists may provide verbal cues (e.g., “BIG steps!”) to encourage the patient to stay mindful of large movements.

C. Dual-Task Training Patients with Parkinson’s often struggle with multitasking. Incorporating dual-task exercises helps improve cognitive function alongside motor control.

Examples of Dual-Task Exercises:

Walking while counting backward or saying the alphabet aloud.

Balancing on one foot while responding to simple questions.

Instructions Start with simple dual tasks and gradually increase the complexity as the patient improves. (Duncan and Earhart, 2012).

4. Home Exercise Plan The success of the Big Program relies heavily on daily home practice.

Duration: Patients perform their personalized exercises for 10-15 minutes every day. Tracking Progress: The therapist provides a log for patients to record their daily practice and monitor improvements.

Family or caregiver involvement: Caregivers are encouraged to help patients stay motivated and ensure exercises are performed correctly.

5. Progress Monitoring and Program Adjustments

Throughout the four-week program, the therapist monitors the patient’s progress and adjusts the exercises based on improvements or new challenges.

If the patient shows improvement, exercises may become more challenging (e.g., longer walking distances or more complex dual-task activities).

If the patient experiences difficulty or fatigue, exercises may be modified to prevent injury and frustration. (Schenkman et al., 2012).

6. Safety Considerations and Modifications Environment: The exercises should be performed in a safe, clutter-free space to reduce the risk of falls.

Support Tools: Patients who struggle with balance may use chairs, walls, or walkers for additional support.

Rest Periods: Patients can take short breaks between exercises to avoid exhaustion. Medication Timing: Patients are encouraged to perform exercises when their medications are at peak effectiveness, usually 30-60 minutes after intake. (Ebersbach et al., 2015).

7. Program Continuation and Long-Term Maintenance After the initial four-week period, the therapist may recommend ongoing sessions to maintain progress.

Patients are encouraged to incorporate BIG movements into their daily routines permanently. Some may continue working with the therapist periodically to ensure long-term benefits and address any new challenges.

Side Effects

Physical Discomfort: Some participants may experience muscle soreness or fatigue due to the intensity of the exercises involved in the BIG program, especially if they are not accustomed to regular physical activity.

Injury Risk: There is a potential risk of injury, particularly for individuals with advanced PD or those who have significant balance issues. The emphasis on larger movements may lead to falls or strains if not properly supervised. (Padilha et al., 2023).

Limitations

Individual Variability: The effectiveness of the BIG program can vary significantly among individuals. Factors such as the stage of Parkinson's disease, overall health, and prior exercise experience can influence outcomes.

Need for Trained Instructors: The program requires trained therapists to ensure that exercises are performed correctly and safely. Access to qualified professionals may be limited in some areas, which can hinder participation.

Time Commitment: The program typically requires a significant time commitment, with sessions often scheduled multiple times per week over several weeks. This may be challenging for some patients due to scheduling conflicts or fatigue. (de Carvalho et al., 2018).

Disadvantages

Cost: Participation in the BIG program may involve costs related to therapy sessions, which can be a barrier for some patients, especially those without adequate insurance coverage. Limited Focus: While the BIG program effectively addresses motor symptoms, it may not adequately address non-motor symptoms of Parkinson's Disease, such as cognitive decline or emotional issues, which are also critical for overall well-being.

Motivation and Adherence: Some patients may struggle with motivation to participate consistently in the program, particularly if they do not perceive immediate benefits or if they experience discomfort during exercises. (de Carvalho et al., 2018).

While the BIG Training Program offers valuable benefits for improving motor function in individuals with Parkinson's disease, it is essential to consider the potential side effects, limitations, and disadvantages. Proper assessment and support can help mitigate some of these challenges.

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