the science and practice of lsvt big & lsvt loud within the

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The Science and Practice of LSVT BIG & LSVT LOUD Within

the Home Health Setting:Building a Successful Clinical Program

This work was supported, in part, by the: National Institutes of Health - R01 DC1150, R21DC006078, R21 NS043711, Michael J. Fox Foundation, Parkinson Alliance and Davis Phinney Foundation

Learning Objectives

• Briefly discuss development and data on an efficacious speech treatment LSVT LOUD™

• Describe development and key aspects of limb motor treatment LSVT BIG™

• Describe the use of/adaptation of LSVT BIG and LSVT LOUD administered in the home.

• Describe the variety of patients that can be treated in the home.

• Discuss reimbursement for LSVT BIG and LSVT LOUD provided in the home setting.

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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

Legitimate Therapeutic OptionsTo provide symptomatic relief; improve function

Pharmacological(L-dopa)

Voice and Body Exercise

Neurosurgical(DBS-STN)

Zigmond et al, 2009

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Video Example:

• 59 year old female• 2.5 years post-diagnosis• On-meds pre and post video

Pre/post LSVT LOUD(Lee Silverman Voice Treatment)Intensive physical exercise of speech mechanism

Insert Short Shirley Video Here

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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

Insert LSVT Walk BIG video here

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Case Study Outcomes:

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

PRE POST

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…

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“If only we can hear and understand her”Family of Mrs. Lee Silverman 1987

Administered in an intensive manner to to challenge the impaired system.

Techniques specific to PD-specific deficits!bradykinesia/hypokinesia

and kinesthetic awareness

(sensory deficit)

LSVT Programs

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SOFT

LOUD

HEALTHY LOUDNESS

Loud is more than a laryngeal event – spread of effects

TARGET

What are the LSVT LOUD exercises?Daily tasksFirst half of treatment sessionRescale 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 sessionTrain amplitude from CORE exercises into in context specific and variable speaking activities

• Week 1 – words, phrases• Week 2 – sentences• Week 3 – reading• Week 4 - conversation

MODE

Shorter, simple

Longer, more complex

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MISMATCH betweenon-line perception ofoutput and how othersperceive it

“I’m not too soft”“I can’t speak like this,

I am shouting!!”Fox et al, 2002; Sapir et al, 2011

CALIBRATION

Ramig et al., 2001; JNNPLevel 1 Evidence Goetz,2003

60

65

70

75

-2 0 2 4 6 8 10 12 14 16 18 20 22 24

Months

SP

L R

ain

bo

w (

50 c

m)

LSVT R

RESP & VOICE (LSVT® LOUD)

RESP

N=45

Blinded, no med changeSame time medStrobe (Smith)EMG

Established Clinical Efficacy

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Advances in Clinical Efficacy(Ramig et al, 1995; 1996; 2001a; 2001b; Goetz, 2003)

Cross-system effects, Neural changes

Spielman, Borod (2003)

(facial expression)

El-Sharkawi, Logemann(2002)

(swallowing)

Smith, M. (1995)

(adduction)

Ramig & Dromey(1996)

(aerodynamics)

Baker (1998),

Luschei (1999) (EMG)

P. Fox, Liotti(2003)

Narayana (2010)

(PET) Dromey, (1995) (articulation)

Sapir (2007; 2010)

(articulatory acoustics)

Smith,A. (2001)(STI)

Taskoff (2001)

(perceptual)

Huber, Stathopoulos, (2003)

(respiratory kinematics)

LSVT LOUD® LSVT BIG ®

(Ebersbach et al, 2010; Farley & Koshland, 2005; Fox, et al., 2012)

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What are the fundamentals of LSVT BIG?

TARGET: Bigness (amplitude)

MODE: Intensive and High Effort

CALIBRATION: GeneralizationSensoryInternal cueingNeuropsychological changes

Standardized, research-based, specific protocol

BIG (Large amplitude whole body movement)Single Target - Triggers Activation across motor systems

SMALLBIG

TARGET

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Delivery– Certified LSVT BIG 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)

MODE

MISMATCH betweenon-line perception ofoutput 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!!”

CALIBRATION

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Problem in self-perception/awareness -do not recognize movements

are small or slow

Produce slow, small movements

Reducedamplitude of motor output

Self-cueing deficits -continue scaling reduced

amplitude of movement patterns

PRE-TREATMENT

Fox et al., 2012

Improve self-perception/awarenessof amplitude required to

produce normalmovement amplitude

Produce larger movements

INCREASEamplitude of motor output

Improve self-cueing/attention to action -habitually scale increased amplitude

of movement patterns

TREATMENT FOCUS

Fox et al., 2012

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LSVT BIG: Data

Comparing Exercise in Parkinson’s Disease —The Berlin LSVT BIG 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 Wissel3

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Comparing Exercise in Parkinson’s Disease —The Berlin LSVT BIG 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 Wissel3

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 BIG (interrupted line) compared to WALK (dotted line) and HOME (solid line), P <0.001. 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

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Initial 3/15/2010

Discharge 4/8/2010

Generalized Amplitude: Uncued writing post-treatment and untrained during therapy

Buttoning BIG Video

Insert short buttoning revised

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LSVT BIG: Treatment Protocol

OVERVIEW – PROTOCOL

• 4 consecutive days a week for 4 weeks

• 16 sessions in 1 month

• 60 minute sessions

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LSVT BIG Treatment SessionMaximal Daily Exercises1.Floor to Ceiling – 8 reps2.Side to Side – 8 each side3.Forward step – 8 each side4.Sideways step – 8 each side5.Backward step – 8 each side6.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 TasksPatient 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 BIG

Distance/time may vary

Maximum Sustained Movements

Floor to Ceiling Side to Side

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Floor to Ceiling

Video – Floor to Ceiling

Insert HH DVD clip of this exercise

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Side to Side

Video – Side to Side


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Multidirectional Repetitive MovementsStep and Reach

Forward Step Sideways Step Backward Step

Multidirectional Repetitive Movements Step and Reach

Forward Step

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Video – Step Forward



Sideways Step

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Video Step Sideways



Backward Step

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Video – Step Backward


Multidirectional Repetitive MovementsRock and Reach

Sideways Rock and Reach Forward/Backward Rock and Reach

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Forward/Backward Rock and Reach

Video Forward Rock and Reach


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Sideways Rock and Reach

Video – Sideways Rock and Reach


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• Rolling

• Floor to Stand

• Getting in or out of bed

• Sit to stand

• Sit & reach

• Stand & reach

• Walk & reach

• Walk & turn

• Stand & turn

Functional Component TASKS

Functional Components – Patient DRIVEN!

Sit to stand BIG

Video - Sit to Stand


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Hierarchy Task Examples

“Real-World” BIG Tasks – Patient DRIVEN!

In/Out of Car

Walk and Talk

ADL’s

Writing

Tennis

Chores

Golf

Hiking

Gardening

Getting in/out of bedLaundryGoing out to church/restaurantPlaying with children/grandchildrenShoppingTransportation: train/bus/carGetting the mailCleaning the house

Bed mobility hierarchy: Pre-LSVT BIG

Copyright LSVT Global, Inc. 2011

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Bed mobility hierarchy: Post-LSVT BIG

Copyright LSVT Global, Inc. 2011

LSVT BIG TREATMENT GOAL

People with Parkinson disease will use their bigger movements

“automatically” in everyday living –

and there will belong-term carryover

of increased amplitude use!

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The Bottom Line• 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 BIG is one type of physical therapy program that has potential to offer improvements in movement

and quality of life for people with PD

LSVT BIG® and LSVT LOUD®

in the Home Health Setting:

BIG challenge or

BIG opportunity?

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Challenges• Patient complexity and

disease severity

• Coordination with other health care providers coming into the home

• Specific knowledge needed to support reimbursement and provision of LSVT BIG in the home

Opportunities• Evaluation of real world

function in context

• Training in context- BIG Walking, exercises, etc.

• Increased ease creating salient Functional Component Tasks, Hierarchies and Carryover Assignments

• Caregiver training in context

• Reduced “travel fatigue” for patient

LSVT BIG and Home Health• Traditional home health practice

– Medicare Part A covers skilled need in homebound patients with chronic conditions

– Typically later stage patients with complex medical history

• Outpatient in the home– Medicare Part B reimbursement for home and

community-based care

• ”House calls” -- cash-based practices– All stages of patients --– Done in privacy of home at client’s

convenience

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Implementation of Intensity

• Is it Reimbursable?

• Is it Practical and Feasible?

• Can patients with Advanced PD or frailty handle therapy 4x/week?

• Is it Applicable to Varied Practice Settings?

YES!

• Eminently reimbursable

– Patients make significant progress

– Medical necessity readily proven in PD

– People with progressive disease get better, even in advance PD!

– Real world experience with 1000+ patients

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Is it Reimbursable in Home Health?

YES!– Medicare Part A covers care for homebound

patients

• Jimmo vs. Sebelius– 2013 lawsuit in which resulted in Medicare

covering maintenance as long as skilled care is required.

– Easy to demonstrate LSVT BIG is skilled care

Practical and feasible • High rate of attendance and participation

• May require education of administration and scheduling changes

• Intensity within sessions scaled to patient’s capabilities

• Intensity and repetition across sessions needed even MORE with advanced PD/more complex presentation

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Applicable to varied practice settings

• Able to regulate intensity and adapt or progress movements according to patient abilities and safe parameters

• Successful implementation in home health, outpatient, skilled nursing facilities, private practice, etc.

• Can be provided by PT and OT together

LSVT BIG Across the Continuum

THEREFORE:

• LSVT BIG can be started by in-patient therapist

• Transferred to Home Care therapist

• Then to an Outpatient therapist as they improve.

Know your network!!

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Later Stage PD patients

• Home Health may be first and only setting

• Home Health LSVT BIG is still LSVT BIG…– Skilled care with first episodes and tune ups

– Basic ADL focus

– PT/OT split

– Caregiver focus

– Single focus on amplitude

LSVT BIG and Maintenance Care

• Marking G codes – Required by Medicare to differentiate patients

who receive skilled care for maintenance purposes

• Skilled home health: Remember that later stage PD patients are not necessarily maintenance patients!– Differentiated with G codes when training for

hand off to caregivers

– Focus on Function to meet Conditions of Participation!

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LSVT BIG and Skilled Home Health Documentation

• Starts with OASIS C1 comprehensive assessment

– Establishes “reasonable and necessary” using functional scores for M1800’s

– Establishes criteria for PT/OT collaborative delivery of LSVT BIG

• 2x4 week frequencies each for PT and OT delivering coordinated LSVT BIG protocol

LSVT BIG and Skilled Home Health Documentation

• Break down into Long Term Goals/Short Term Goals

• Focus on calibration improvements for functional tasks

• Focus on clear identification of patient goals and degree of disease self-management

• Focus on graded improvements in caregiver competency for advanced patients

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LSVT BIG and Skilled Home Health Outcomes

• LSVT BIG skill contributes to agency publicly reported outcomes and STAR ratings

• Clinical framework for reducing falls, meeting identified skilled need, improving publicly reported outcome ratings for agencies

Practical Tips for Implementation and

Documentation

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What is “Advanced” PD?Modified Hoehn and Yahr Scale

• STAGE 0 = No signs of disease.• STAGE 1 = Unilateral disease.• STAGE 1.5 = Unilateral plus axial involvement.• STAGE 2 = Bilateral disease, without impairment of balance.• STAGE 2.5 = Mild bilateral disease, with recovery on pull test.• STAGE 3 = Mild to moderate bilateral disease; some postural

instability; physically independent.• STAGE 4 = Severe disability; still able to walk or

stand unassisted. • STAGE 5 = Wheelchair bound or bedridden unless aided.

Goetz CG, Poewe W, Rascol O, et al. Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: status and recommendations. Mov Disord. 2004;19(9):1020-28.

Recommended Assessment Tools for Patients with

Advanced PD• PT: Berg, TUG, 10 meter Walk, ABC

• OT: PASS, MOCA or SLUMS, 9 Hole Peg

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Adaptations to LSVT BIG Maximal Daily Exercises

Stepping and Rocking Exercises-Unilateral Support Demos

• Support location

• Facilitation and shaping techniques

• Temporary use of external cues to scale or drive amplitude

This image cannot currently be displayed.



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Stepping and Rocking Exercises-Seated Adaptations

Stepping and Rocking Exercises-Seated Adaptations

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LSVT BIG Exercises Adapted to Supine

SUSTAINED STEPPING ROCKING

LSVT BIG Exercises Adapted to Supine

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Case Example

Tony: H&Y Stage 4

• 82 y/o homebound male, retired, PD x 8 years, co-morbidities including HTN, atrial fibrillation, dementia, Stage II sacral decubitus ulcer, incontinence, hallucinations with Mirapex

• Lives in two story home, garage ramp, with devoted elderly wife with intermittent paid caregiver support

• Postural changes and skin breakdown as a result of disease progression (marked kyphosis, leaning left unless continually cued)

• Interests: Golf (riding golf cart, putting), dinner and socializing with large extended family

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Functional Component Tasks

1. Sit to Stand

2. Rolling BIG in Bed

3. Stepping BIG at toilet

4. Throwing off bedcovers BIG

5. Reaching for tissue BIG

Hierarchy: Bed Transfers• Week One: Blocked practice

• Week Two: Short sequences, primary caregiver providing cues, sheets vs. sheets plus comforter on bed, varied clothing (pajamas vs. daytime clothing)

• Week Three: longer sequence, primary and paid caregiver providing cues, varied lighting, varied weight of bedclothes eg. added blankets

• Week Four: whole sequence, environmental distractors (television, nearby conversations), internal distractors (urgency for toileting), time constraints, directing new caregiver

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Home Health Short Term Goals for Tony

• Short Term Goals– Patient will remove varied-weight bedcovers

using caregiver-cued BIG movements 50% of the time

– Patient will move supine to sidelying with caregiver-cued BIG movements with varied clothing/bed clothing, 50% of the time

– Patient will move sidelying to sitting with rail assist and caregiver-cued BIG movements 50% of the time

Home Health Long Term Goals for Tony

• Long Term Goals– Patient will complete safe transfer supine to

bed edge sit with single caregiver cue to initiate sequence for BIG rolling, and Standby Assistance for BIG sidelying to sit with rail support, 100% of the time

– Patient will independently provide verbal instruction to paid or novice caregiver for set up and positioning for successful completion of BIG transfer supine to bed edge sit 100% of the time

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Tony’s Outcomes

• Transfers supine to bed edge sit with single verbal cue, using rail assistance

• Able to instruct caregiver verbally and understandably in steps to sequence for BIG transfer supine to bed edge sit

Video Examples

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Side to Side in home

Sit to Stand In Home

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Big Walking In Home

Tips for Success When Implementing LSVT BIG

and LSVT LOUD Program

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Address Scheduling Challenges

• Challenge #1: Home Health visits may include vital sign and physical assessment, adding to total visit time

• Challenge #2: Management pressures to reduce weekly frequency to fit number of visits for maximizing reimbursement

• Challenge #3: Medical frailty/co-morbidities may affect plan of care and frequency due to missed visits

The LSVT BIG TEAM Approach!LSVT BIG Certified OT & COTAs

LSVT BIG Certified PTs & PTAs• PTAs or OTAs who are involved in the administration of LSVT BIG must

successfully complete an LSVT BIG Training and Certification Workshop. The PTA or OTA will not be able to deliver the treatment independent of a Certified LSVT BIG PT or OT.

• LSVT BIG Certified PTAs and OTAs may perform tasks as prescribed, directed, and supervised by an LSVT BIG certified PT or OT respectively.

• Assessment of the PTA’s or OTA’s skills with assigned tasks by the supervising PT or OT respectively should be an ongoing, integral element of supervision with frequent feedback provided.

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Teaming together with the LSVT LOUD certified SLP’s

• Cross refer- screen and educate

• Screen for need for tune-ups

• Support calibration- don’t let a soft voice slip by

• Understand what that person’s “best” healthy voice quality sounds like

• Educate on functional tasks (e.g. BIG posture or BIG walking) that could be reinforced by the LSVT LOUD clinician

Address Reimbursement Challenges

• Challenge #1: Non-Medicare plans require prior authorization

• Challenge #2: Clear documentation of homebound status required each visit, up to #16, to be 100% reimbursible

• Challenge #3: Skill documentation focusing on therapist actions in modeling, shaping, adding complexity required with functional outcome focus

• Challenge #4: Reimbursement for PT and/or OT requires OASIS functionals score = Medical Necessity

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Tune-Up Recommendations

• Establish frequency and number of visits based on assessment findings– Range: 0 -16 visits! Average 4-6 visits

– Continue to follow patients every 3-12 months• More Frequent (every 3-4 months): Atypical PD,

Cognitive Impairments, with changes to DBS

• Less frequent: IPD, Young, healthy, very motivated and adherent to HEP, good support, active

– Remember….PD is forever! You are an important partner on their journey!

Tune-ups are legitimate reimbursable “care” for people with degenerative diseases.

You should establish the tracking schedule for f/u prior to discharge

standard of care.

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General Documentation Reminders

– What is skilled?• Requires YOUR skill, instruction and intervention

as a therapist to achieve the goals.

• Could not have been done by lay persons or a care partners or by the patients themselves without you in the picture

– What is medically necessary?• Therapy required for improved safety, quality of life,

decreased disability, etc.

– Is there reasonable expectation of significant progress?

• How can you show that improvement?

Therapy and Homework Quantification Variables

Time to complete daily tasks; functional tasks # reps completed, with comments on your

shaping, assessing and modifying patient behavior

Step size Duration of sustained postures “reported functional improvements” HR average across a session/Borg effort Progression in hierarchies Changes in amount of cued vs. uncued trials

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Statements Supporting Reimbursement

• Mrs. P increased amplitude of upper extremity movements which enabled her to write lists and sign her name legibly on documents.

• Mr. G is now able to don his socks and shoes without his wife’s help or cueing and in less than 1 minute, by using increased amplitude and effort.

Marketing LSVT Programs

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LSVT BIG and LSVT LOUD Improve Outcomes...

LSVT BIG Reduces Fall Risk...

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In Summary• LSVT BIG and LSVT LOUD are adaptable

for patients at all stages of Parkinson’s Disease

• LSVT BIG and LSVT LOUD are applicable and practical for patients within the home setting using principles of intensity and single focus

• LSVT BIG and LSVT LOUD are reimbursable and important tools in developing comprehensive plans of care and improving publicly reported outcomes

“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 KhaLSVT BIG and LSVT LOUD Graduate

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QUESTIONS??

the science and practice of lsvt big & lsvt loud within the

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