Lee Silverman Voice Treatment–BIG ® in Stroke: A Case Study

PURPOSE: Literature suggests the Lee Silverman Voice Treatment–BIG^® (LSVT–BIG) program is an effective intervention for individuals with Parkinson’s disease (Ebersbach et al., 2015); however, no literature or research exists on the use of this program as an intervention for individuals with stroke. Therefore, this project aims to measure the effectiveness of the LSVT–BIG program with one individual with a stroke to determine if LSVT–BIG is a feasible and effective occupational therapy intervention for this population.

The LSVT–BIG program is an intensive program with hands-on treatment sessions 4 days/wk for 4 wk. Clients complete home exercises every day that enhance the hands-on treatment and help promote carryover of skills learned to daily tasks. We have previously investigated the use of game-based technologies for the delivery of home exercise programs with this population (Proffitt & Lange, 2015). For this study, the home exercises were completed by the participant using a game. Therefore, this project aimed to measure the effectiveness of the LSVT–BIG program with one individual with a stroke to determine if LSVT–BIG is a feasible and effective occupational therapy intervention for this population. The secondary aim was to determine the feasibility of delivering the in-home exercises via a game-based virtual reality system.

DESIGN: This was a case feasibility study with measurements at three distinct time points: pretesting, posttesting, and 6-wk follow-up. One individual with chronic stroke (>6 mo poststroke) was recruited from a no-fee student-run clinic. The participant was a woman age 52 yr who was community dwelling, was independent in all activities of daily living and mobility, and had mild to moderate upper-extremity hemiparesis affecting the left side.

METHOD: The intervention followed the standard LSVT–BIG protocol and was delivered by a trained intervener. The protocol is delivered four consecutive days per week over 4 wk. Each treatment session lasts 60 min and includes a combination of exercise and functional tasks. For this study, the client completed the associated home program via a virtual reality–based game called Mystic Isle (University of Southern California Institute for Creative Technologies, Los Angeles). Movements were tracked and recorded via the Kinect (Microsoft, Redmond, WA) and used to interact with the virtual world.

The primary outcome measures used include the Canadian Occupational Performance Measure (COPM), Stroke-Specific Quality of Life Scale, Performance Assessment of Self-Care Skills, Modified Ashworth Scale, Wolf Motor Function Test (WMFT), range of motion, and manual muscle testing. Scores on all assessments were compared over time; however, no statistical methods were used as this was a case study.

RESULTS: The client completed 100% of in-clinic visits and 85% of the home program with 50% of that using the Mystic Isle software. The client demonstrated self-reported improvements in performance of (change score = 4.0) and satisfaction with (change score = 5.2) identified occupations on the COPM. The client demonstrated great improvements in time (7.78 s pretest, 4.14 s posttest, 12.45 s follow-up) on the WMFT. The client increased her left shoulder flexion and abduction to within normal limits and had a clinically and functionally significant increase in left thumb extension from 10° of extension to nearly full extension. The client also reported the introduction of new occupations such as pulling weeds in the garden and swimming.

CONCLUSION: The results of this study suggest it is feasible for rehabilitation professionals to use LSVT–BIG with individuals with chronic stroke. LSVT–BIG has the potential to have a positive effect on motor function and occupational performance for individuals with chronic stroke as evidenced by findings on the subjective and objective outcome measures. Further, it is feasible to deliver the home exercise portion of the LSVT–BIG program using a computer-based gamified system. Incentives and feedback need to be systematically incorporated to ensure long-term use and increase adherence. The next step in this research is to deliver LSVT–BIG and the gamified home program to a larger, more diverse population with chronic stroke to further determine the effectiveness and appropriateness of this intervention.

IMPACT STATEMENT: This is the first study investigating the use of a standardized protocol, the LSVT–BIG program, with a member of the chronic stroke population. The positive findings from this case study suggest that this intervention can be effectively used with clients with stroke and in occupational therapy practice.

References

Ebersbach, G., Grust, U., Ebersbach, A., Wegner, B., Gandor, F., & Kuhn, A. A. (2015). Amplitude-oriented exercise in Parkinson’s disease: A randomized study comparing LSVT–BIG and a short training protocol. Journal of Neural Transmission, 122, 253–256. https://doi.org/10.1007/s00702-014-1245-8

Proffitt, R., & Lange, B. (2015). The feasibility of a customized, in-home, game-based stroke exercise program using the Microsoft Kinect sensor. International Journal of Telerehabilitation, 7(2), 23–33. https://doi.org/10.5195/ijt.2015.6177