Published: May 31, 2009 3:00 a.m.
Parkinson's plan takes Big step
Michael Schroeder
The Journal Gazette

Sitting at home in Huntington, Bill Bieghler, 81, turns a golf putter over 
in his hand, studying it.

His wife, Mary, brought the club to him at the request of a visitor, but 
there's another putter he favors more, he says, his stiff fingers cupping 
the familiar rubber grip.

Putting was the last thing to go when Bieghler gave up golf a couple years 
ago - advanced Parkinson's disease making what was once a daily pleasure 
impossible.

But Bieghler's hoping he'll get another swing at it after undergoing a new 
intensive in-home therapy program guided by clinicians at Parkview Home 
Health and Hospice. Parkview was the first in Indiana to have clinicians 
certified in the therapy program.
Bieghler was diagnosed with Parkinson's in 1990, and his balance has 
suffered, making walking difficult. The degenerative disease disrupts the 
brain's production of a chemical called dopamine, which is crucial to 
smooth, coordinated muscle function and movement.

He uses a walker, or else Mary puts all of her slight frame into stabilizing 
him by grabbing a bright blue belt he wears for just that purpose. Sometimes 
he walks without any assistance, though she wishes he wouldn't.

Swinging a club is even tougher, with all the whirling motion's implications 
for balance.

But, "This exercise has loosened me up," said Bieghler of the four-week 
physical and occupational therapy program he completed this month. That's 
got him pining for another round at Norwood Golf Club on the edge of 
Huntington, where he once worked and played golf for free.
Therapy catches on

Called LSVT Big, the therapy program Bieghler underwent encourages big, 
exaggerated steps and stretches. This is meant to counter progressively 
smaller, slower movements that restrict life for many people with Parkinson's.

The program stems from the success of a speech therapy program introduced in 
the late 1980s, now called LSVT Loud, which Bieghler completed prior to LSVT 
Big.

(The acronym LSVT comes from the name of a woman with Parkinson's, Lee 
Silverman, for whom voice training was first developed.)
The therapies are a complement to - not a replacement for - medications and 
surgical interventions, said Cynthia Fox, chief clinical officer and 
cofounder of Tucson, Ariz.-based LSVT Global, which trains clinicians on the 
programs. The first training and certification courses on LSVT Big started 
in 2007, and more than 350 clinicians are now certified.

Patients are guided through one-hour sessions four days a week and are 
expected to do stretching exercises on their own time as well.
Having completed the formal part of the program, Bieghler is expected to 
continue doing daily exercises, though other things - computer games, 
visitors - compete for his interest, Mary said.

The payoff: The couple, who will be married 60 years in August, find it 
easier to go out now. Bieghler has missed working in the yard and hopes to 
do some of that as well.

In addition to four Parkview clinicians certified in LSVT Big, another 
clinician in Indianapolis is now certified to provide the therapy. Many 
more - including at Parkview - are also certified in LSVT Loud.

Parkview competitor Lutheran Health Network has clinicians trained in LSVT 
Loud and plans to have two physical therapists trained in LSVT Big at the 
beginning of June.

LSVT Big and Loud are essentially - at least to patients - about being just 
that, big and loud.

People with Parkinson's tend to slow down, to get quieter and to draw within 
themselves as their sense of motor control diminishes. The change can be 
imperceptible.

Often times, their spouse thinks they need a hearing aid, said Cynthia Fox 
of LSVT Global. In reality, they can hear just fine.
LSVT therapies focus on retraining sensory perceptions, Fox said. So, what a 
patient might think too big or loud, they recognize as within the normal 
range.

For LSVT Big, clinicians remind patients to "think big" in all they do. 
Clinicians model movements. They reach toward the ceiling and the floor; 
they rotate at the waist, stretching seated and standing; they step out.

The simple visual cues are a departure from more complex verbal instruction, 
said Betsy VanMarkwyk, clinical manager of rehab for Parkview Home Health 
and a speech pathologist. Seven patients have completed the program locally, 
and it has shown early promise.

"Our traditional methods for working with Parkinson's patients . have not 
always proven to be very effective," VanMarkwyk said.

Optimistic, realistic
Fox said long-term studies are still needed to document the effect of 
behavioral intervention in people with Parkinson's disease. But she said a 
study on rats showed that intensive exercise soon after the onset of the 
disease slowed or in some cases almost halted the progression of the 
disease.

Rose Wichmann said Parkinson's research on animals showing how behavioral 
intervention can protect brain cells is exciting.
Wichmann is an LSVT Big-certified physical therapist and manager of the 
Struthers Parkinson's Center. The underlying message is that people with 
Parkinson's need to remain active, she said, and enlist the help of a rehab 
professional to find a program that's right for them.
Wichmann and her team use the protocol for patients with early to mid-stage 
Parkinson's. Limited research on LSVT Big has focused on patients in this 
subgroup showing improvement in range and speed of movement. The more severe 
a patient's condition, the milder the improvement was measured to be.

Wichmann said she wouldn't recommend LSVT Big for those with the most 
advanced stages of Parkinson's disease. Apart from a lack of research on 
this group, patients with more advanced Parkinson's have more physical and 
perceptual limitations that make it harder for them to follow the protocol.

Parkview charges $180 per day for the therapy, the same it charges for other 
therapies. The therapy is covered by Medicare and most other private 
insurers. The increase in function and independence resulting from the 
therapy is likely to save money on associated care, Parkview officials said.

Slowing the march of Parkinson's might seem pie-in-the-sky to some, but 
clinicians hope to help patients maintain physical and speech functions as 
long as possible.

"The hardest thing" about Parkinson's disease, Bill Bieghler says, "is not 
knowing what it's going to do."
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Rayilyn Brown
Director AZNPF
Arizona Chapter National Parkinson Foundation
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