Evidence-Based Programs for Parkinson’s Disease: A LSVT BIG Case Report and Summary of the Evidence Surrounding Treadmill Training, Tai Chi, Dance, and Boxing

Evidence-Based Programs for Parkinson’s Disease: A LSVT BIG Case Report and Summary of the Evidence Surrounding Treadmill Training, Tai Chi, Dance, and Boxing

By: Kate Finegan, SPT

Background

My interest in Parkinson’s Disease stems from a personal connection to the disease, a fascination with neurology and neurodegenerative disorders, and the Neuromuscular II coursework in the curriculum.  I first learned about the LSVT BIG program through my grandfather that had completed the program upon first being diagnosed with Parkinsonism.  In my first year of PT school, I decided to pursue the LSVT BIG certification with hope that I could one day implement it into my clinical practice.  A year later, I was assigned a clinical rotation at Vidant Medical Center in Greenville, NC, and I quickly learned that my clinical instructor was LSVT BIG certified as well.  I thoroughly enjoyed getting the opportunity to work with patients with Parkinson’s Disease, as well as the opportunity to utilize my LSVT BIG certification in real patient scenarios under the supervision and guidance of a more experienced PT.  At that point in time, I knew that I wanted to further explore the use of LSVT BIG in patients with Parkinson’s Disease, but I also recognized that interventions do not exist in a vacuum and that there is a plethora of available evidence about additional interventions for this patient population.  This capstone project and its associated products represent the culmination of almost a year’s worth of work to broaden my knowledge of evidence-based interventions and the mechanisms that make them effective, in an effort to improve my own clinical reasoning skills and provide valuable education materials to patients and clinicians looking to make a decision about which Parkinson’s Disease interventions to pursue.

 

Overview/Purpose

Parkinson’s Disease is the second most common movement disorder and one of the most prevalent neurological conditions, occurring in approximately 3.3% of individuals over 65¹.  The symptoms seen with Parkinson’s Disease are caused by a loss of dopaminergic neurons in the substantia nigra of the basal ganglia and the subsequent depletion of the neurotransmitter dopamine².  As such, the primary motor features of Parkinson’s Disease include: bradykinesia, resting tremor, rigidity, and impaired posture².  The literature has demonstrated that exercise, if performed regularly and implemented early, can have a neuroprotective effect on the dopaminergic neurons thus slowing the progression of motor deficits².  Some key principles of exercise that have been identified in the literature as important in enhancing neuroplasticity in patients with Parkinson’s Disease include intensive activity, complex activity, and rewarding activity³.  However, the literature is relatively scarce when it comes to specific mechanisms and characteristics of effective interventions.  Thus, the purpose of this capstone project is to present two case studies of patients undergoing LSVT BIG; analyze and report on the evidence surrounding LSVT BIG^2,4, treadmill training⁵, Tai Chi^6,7, dance^3,8, and boxing⁹; and to identify common underlying mechanisms of intervention effectiveness.

 

Statement of Need

The catalyst and inspiration for my capstone project came from a real need for educational use by a clinician in the community.  My clinical instructor, Joshua Mitchell, PT, is LSVT BIG certified, and he expressed to me the lack of knowledge surrounding the certification and protocol amongst patients, physicians, and other therapists.  As such, my clinical instructor and the clinical coordinator, Glen Newman, PT, MPH, GCS, at Vidant Medical Center expressed interest in me collecting data on a patient that was undergoing the LSVT BIG protocol, and creating an easily-distributed and accessible product that analyzes the effectiveness of LSVT BIG and other evidence-based treatment interventions. The audience for this project included those individuals mentioned previously, as well as clinicians at the UNC Center for Rehabilitation Care.

 

Products

In preparation for this capstone project, I completed a Critically Appraised Topic (CAT) for the clinical question, “In female older adults (70 or older) with Parkinson’s Disease, is the LSVT BIG program or the use of external visual cueing more effective in improving gait?”.  This assignment allowed me to explore and analyze the current best evidence for LSVT BIG as compared to various interventions that employed external visual cueing, and provided the foundational basis for my final capstone products^1,4.

The primary product developed was a narrated presentation (password: movebig) for clinicians and patients that included the presentation of two LSVT BIG case studies, a review and analysis of the evidence surrounding the interventions of interest, and an analysis of potential mechanisms of effectiveness for the interventions explored.  Additionally, an evidence table exploring the best evidence for the use of LSVT BIG^2,4, treadmill training⁵, Tai Chi^6,7, dance^3,8, and boxing⁹ was created to supplement the narrated presentation.  This allowed the presentation discussion to be more generalized and focused on key points for the sake of time and in consideration of the health literacy of patients who may be the recipient of this education.

 

Evaluation

Throughout this capstone process, I have been privileged with the opportunity to seek and respond to feedback at multiple stages.  I sought feedback from my committee members and capstone advisor after completion of the content outline that I then incorporated into my final products.  Once my products were completed, I once again asked for the feedback of my committee members and capstone advisor.  Finally, I was extremely lucky to have been asked to give my presentation live at both Vidant Medical Center and the UNC Center for Rehabilitation Care.  This allowed me to request and receive feedback from the very clinicians that comprise my target audience.

 

Self-reflection

Overall, I am extremely pleased with the outcome and products of this capstone project.  I was able to meet, and exceed, all of my personal learning objectives and the learning objectives for the presentation audience.  I hope that the materials created will be of great educational use in the clinic for both clinicians and patients.  An unexpected challenge that I faced during this process was the challenge of technology, as I found it particularly difficult to produce and synchronize a presentation that contained both audio and video components, and to convert file types in order to upload the presentation to a website for easy access.  Although I did my research on the front end about this process, and I am extremely pleased with the final media, additional preliminary research could have saved some time and stress, or perhaps a different medium would have been more appropriate and user-friendly.

I was thrilled with the opportunity to give my presentation to two live audiences; I have a passion for teaching and a desire to pursue that as an aspect of my career in the future and this project allowed me to cultivated that further.  It was beneficial to give the two presentations a few weeks apart, as it allowed me to reflect on how the first one went and the feedback I received from the audience.  The biggest change that I made between the two presentations was cutting down on the report of specific data from the two case studies, as I felt that took up necessary time when the audience members could clearly read and see the change in outcomes while I was discussing the clinical significance.  I also made it a point to reprioritize my points of emphasis in order to improve my time efficiency.  This was challenging, as my recorded presentation was an hour in duration, but I was tasked with giving the live versions in 45 minutes.  However, brevity is a weakness of mine, and the time constraint really pushed me to analyze and reflect on what big messages I wanted to ensure the audience took home.

The last way in which this project challenged me personally was in learning to be accepting and adaptable to change.  At the beginning of the semester, I laid out a detailed plan for when components of the project would be completed.  However, as life and major projects go, there were changes and bumps along the way that put me off of my originally intended schedule.  While it was personally challenging to accept this fact, I had to learn to re-evaluate the situation and adjust my timeline and plan accordingly in order to meet my goals.

This project provided me with a wealth of new knowledge about intervention options for patients with Parkinson’s Disease, as well as the parameters of an intervention that make it effective.  Though I will not implement these specific interventions in all of the patients I see in the future with Parkinson’s Disease, I now feel confident that I can design a program that gets at the underlying mechanisms of effectiveness discussed.  This project also further expanded my skills in creating and giving effective, engaging presentations.  Lastly, this project pushed me to expound upon the essential skills learned in the Evidence-Based Practice courses of the curriculum, and facilitated independence and confidence in finding and implementing evidence into daily practice.

 

Acknowledgements

First and foremost, I would like to sincerely thank my capstone advisor, Dr. Prudence Plummer, PhD, PT for her guidance, support, and feedback throughout my capstone experience.  I would also like to thank Vicki Mercer, PT, PhD, my academic advisor, for her early support and guidance in the development of this project and its components.  Thank you to my capstone committee members, Joshua Mitchell, PT, and Diane Meyer, PT, MSCS for helping me recruit case study participants, and for their fantastic feedback and encouragement throughout this entire process.  I am extremely lucky and forever grateful to have gotten the opportunity to work alongside two very experienced, exceptional neuro physical therapists.  I’d also like to extend a great thank you to Hilary Rose, PTA of the UNC CRC for assisting me in the data collection for one of the case study patients.  Lastly, I owe a great deal of appreciation to my two case study participants, Mrs. T and Mr. C, for allowing me to explore my interest and passion for treating patients with Parkinson’s Disease, and for allowing me to share their journey and progress with you all.  Without their willingness to participate, this project would not have been possible.

 

References

1. Rocha PA, Porfírio GM, Ferraz HB, Trevisani VFM. Effects of External Cues on Gait Parameters of Parkinson’s Disease Patients: A Systematic Review. Clin Neurol Neurosurg. 2014;124:127-134.
2. Millage B, Vesey E, Finkelstein M, Anheluk M. Effect on Gait Speed, Balance, Motor Symptom Rating, and Quality of Life in Those with Stage I Parkinson’s Disease Utilizing LSVT BIG®. Rehabil Res Pract. 2017;2017:1-8.
3. Sharp K, Hewitt J. Dance as an intervention for people with Parkinson’s disease: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2014;47:445-456.
4. Ebersbach G, Ebersbach A, Edler D, et al. Comparing Exercise in Parkinson’s Disease-the Berlin BIG Study. Mov Disord. 2010;25(12):1902-1908.
5. Mehrholz J, Kugler J, Storch A, Pohl M, Elsner B, Hirsch K. Treadmill training for patients with Parkinson’s disease. In: Mehrholz J, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2015:CD007830.
6. Yang Y, Li X-Y, Gong L, Zhu Y-L, Hao Y-L. Tai Chi for Improvement of Motor Function, Balance and Gait in Parkinson’s Disease: A Systematic Review and Meta-Analysis. Bayer A, ed. PLoS One. 2014;9(7):e102942.
7. Ni X, Liu S, Lu F, Shi X, Guo X. Efficacy and Safety of Tai Chi for Parkinson’s Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Bayer A, ed. PLoS One. 2014;9(6):e99377.
8. Lötzke D, Ostermann T, Büssing A. Argentine tango in Parkinson disease – a systematic review and meta-analysis. BMC Neurol. 2015;15(1):226.
9. Combs SA, Diehl MD, Chrzastowski C, et al. Community-based group exercise for persons with Parkinson disease: a randomized controlled trial. NeuroRehabilitation. 2013;32(1):117-124.

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