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"Training BIG" Improves Motor Performance in Parkinson's Disease

Buenos Aires, Argentina - Jun 18 2010

In a comparative study, 4 weeks of supervised physiotherapy consisting of repetitive high-amplitude movements yielded greater improvements in motor performance in patients with Parkinson's disease than either Nordic walking or nonsupervised in-home exercises.

Georg Ebersbach, MD, from the Movement Disorders Clinic, Beelitz-Heilstatten, Germany, presented the study here June 14, during the Movement Disorder Society 14th International Congress of Parkinson's Disease and Movement Disorders.

In the so-called "Training BIG" physiotherapy program, derived from the Lee Silverman Voice Treatment (LSVT), and now known as LSVT BIG, patients complete multiple repetitions (minimum, 12) of increasingly complex sustained whole-body movements at maximal amplitude. Examples of BIG exercises include:

Reach left arm across the body to opposite side, keep hand open, palm up, right leg fully extended, toe pushing into the floor. Repeat on other leg and alternate.

Step out and land "BIG," pushing the left foot into the floor while reaching out to the right side with bilateral "BIG arms," open hands, palms up. Return the foot back to the start, end "BIG." Repeat on other leg and alternate.

• Training BIG is delivered by a physiotherapist 4 days a week for 4 weeks, in 1-hour sessions. Therapists push patients to perform at a patient-perceived effort level of 8 or more (on a scale of 1 - 10, with 10 being the highest effort level) on every repetition. Goal-directed activities of daily living (ie, getting out of bed, dressing, doing household chores) are also a focus.
• "The goal of BIG (and LSVT) is to improve movement perception and to recalibrate disturbed scaling of movement amplitudes," the study team explains in the meeting poster.

The Study

The value of the BIG movements approach became evident in a prospective, rater-blinded, comparative study in which 60 patients with mild to moderate Parkinson's disease were evenly and randomly assigned to one-on-one BIG training, Nordic walking in groups (the WALK group), or in-home nonsupervised exercises (the HOME group).

The primary efficacy measure was difference in change in United Parkinson's Disease Rating Scale (UPDRS) motor score from baseline to follow-up at 16 weeks between groups. All but 2 patients (1 in the WALK group and 1 in the HOME group) completed the trial and 16-week follow-up.

In an email to Medscape Neurology, Dr. Ebersbach said there was "sustained improvement of motor performance 3 months after termination of supervised BIG training, [with] superior effect compared to Nordic walking and HOME" (P < .001).

Intensive training with BIG can improve motor performance "to an extent comparable to current drug treatment," Dr. Ebersbach noted.

Average improvement in UPDRS motor score in the BIG trainers was −5.05 (standard deviation [SD], 3.91), which is considered clinically relevant, the study team notes. In contrast, the UPDRS motor score showed mild deterioration of 0.58 (SD, 3.17) in the WALK group and of 1.68 (SD, 5.95) in the HOME group.

BIG was also superior to Nordic walking and in-home exercises in the timed up-and-go test and timed 10-m walking. There were no significant between-group differences in Parkinson's-related quality of life.

The study is scheduled for publication in an upcoming issue of Movement Disorders.

High-Amplitude Exercise

Christopher G. Goetz, MD, director of the Movement Disorders Program at Rush University Medical Center, Chicago, Illinois, and member of the Movement Disorder Society, told Medscape Neurology: "This type of exercise is a notch above average exercising and is purposefully aimed to stress the patient's effort by asking him or her to exercise with high amplitude." Dr. Goetz was not involved in the study.

"Such methods would need to be trained initially," he added, "but conceivably can be incorporated into a patient's self-designed home exercise routine. It is likely, however, that a professional trainer or therapist will help in this effort in order to train the high amplitude effort."

In a statement from the Movement Disorder Society, Cynthia Cornella, MD, from Rush University Medical Center in Chicago, calls the study "innovative" and notes that the result, "extends the findings of the [LSVT] and suggests that similar techniques may be of benefit in other areas of motor impairment in Parkinson's disease." Although the results require confirmation, she adds, "this study provides the impetus for continued investigations into the effects of specific training programs in [Parkinson's disease]."

Dr. Ebersbach and Dr. Goetz have disclosed no relevant financial relationships.

Movement Disorder Society (MDS) 14th International Congress of Parkinson's Disease and Movement Disorders: Abstract LB-08. Presented June 14, 2010.

Source Publication: Medscape Today
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