For those living with Parkinson's, back pain and stiffness can be some of the most frustrating symptoms of the neurological disorder. Luckily, with cutting edge physical therapy programs like LSVT BIG®, those living with Parkinson’s can combat the slowing and smallness of movements associated with the disease. 

Samantha Schroder, DPT, a physical therapist based in Carolina Neurosurgery and Spine’s Charlotte office is certified in the approach. She joins Back Talk Doc host, Dr. Sanjiv Lakhia, to discuss how the program reorganizes nerve networks in the brain to improve functioning.  

The program focuses on big movements, which yield significant improvements in patients committed to the regimen. Samantha explains, “[We] get them to move really big. While it might seem super exaggerated when we act it out, when [the patient] acts it out, it's essentially going to be normal movement because they're starting from a place that's smaller. Having them do things that feel really exaggerated to them is going to look normal to us, and that's one of the main parts of the program.” 

In addition to explaining the science behind the program, Samantha shares exercises that patients can do to improve their posture and decrease back pain, also noting the benefits of integrating diaphragmatic breathing into the routine.

💡 Featured Expert 💡

Name: Samantha Schroeder, DPT

What she does: Samantha Shroeder, DPT, is a licensed physical therapist living in Charlotte, NC. She has extensive experience in treating neuromuscular and musculoskeletal conditions, with specific interest in Parkinson’s Disease. Samantha is certified in treating Parkinson’s using the LSVT BIG® method.

Company:  Carolina Neurosurgery & Spine

Words of wisdom: "I fell into Parkinson’s because, during my clinical rotations, I noticed that it was more common than I had realized. It's the second most common neurological disease in the U.S., and people with Parkinson's can experience moderate to severe functional deficits. I believe that there is a significant role for physical therapy in treating Parkinson's, and that's where my interests stem from."

Connect: LinkedIn | LSVT BIG® Promotion

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice, and now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your back talk doc, Dr. Sanjiv Lakhia.

When most people think about back pain, the idea of degenerative disc disease, disc herniations, muscle pulls, all that seems to come to the forefront, but throughout my clinical career, I've encountered many patients who suffer from neurologic disorders that also deal with back pain on a regular basis, and in particular, the functional decline that can come with neurologic disorders. One of them that I see on a routine basis deals with back and spinal dysfunction in the setting of Parkinson's disease, and I'm really pleased today to bring on to the show my colleague Sam Schroeder, who's a doctor of physical therapy at Carolina Neurosurgery & Spine. So Sam, welcome to the show.

Thank you. I'm happy to be here.

Let me introduce you to everyone who's listening today. You work out of our Charlotte office, correct?

Yes, that's correct.

Excellent. Sam graduated with a Bachelor of Science in Exercise Science from the University of South Carolina in 2018. She received her doctorate in physical therapy from the Medical University of South Carolina in 2021. Her clinical interests include neurological diagnoses and balance deficits, and she's also certified in the LSVT big program used to treat patients diagnosed with Parkinson's disease. She's passionate about health and fitness and helping others and really got into the space due to some issues that you dealt with on your own, right? Through competitive athletics. Really, she just loves to help people get going in the right direction with their pain and their function, and she's really taken to a group of people that deserve the attention. So again, welcome to the show and let's dive in today a little bit about this. Why don't you start by telling people really what's attracted you to the space of dealing with pain and function in Parkinson's?

So I was always interested in neurological diagnoses throughout physical therapy school. I'm just fascinated by the brain and the nervous system and how all of that plays a role in how people can move. Parkinson's I fell into in particular because when I went on my clinical rotations, I started noticing that it was something I was seeing a lot and it was a lot more common than I had even realized. It's the second most common neurological disease in the US, so it really is very prevalent and these people can get very moderate to severe functional deficits from having Parkinson's, so I think there's a huge role for physical therapy in that, and that's really where my interests stem from.

Yeah, that's great. In the clinic, it is not uncommon for me to receive a referral for someone with balance issues and concerns about cervical or lumbar stenosis, and then really just after watching them walk and doing an examination, I start to get suspicious about Parkinson's. For those people listening who aren't familiar, maybe don't have a friend or family member who has suffered from this condition, can you give them a high level just overview or definition of what this is?

Sure. So Parkinson's disease, it's a neurological disease that starts in the brain. So we have a neurotransmitter in the brain called dopamine, which most people have heard of. It's the happy reward producing neurotransmitter hormone, and so in Parkinson's, what happens is patients with this disorder, they start to lose their dopamine producing cells and they just die off. When that happens, they start to get a lot of deficits, both physical and non-physical, but especially in the physical presentation, not having those dopamine cells really slows down their movement. It causes smaller movement patterns, and so it really takes away just their normal movement and functioning.

Yeah. Some of the hallmark signs that we look for, something called bradykinesia, which basically means really slow movement patterns. It can affect how their face will look at times. We call that masked faces where it just looks a little expressionless-

Definitely.

... but make no mistake. Behind that is real emotion and a real person who's dealing with the struggles. The gait pattern, shuffling gait. I'm sure you'll talk about that a little bit.

Definitely.

From my observation, these folks not only can develop a lot of pain and stiffness in their body, but a lot of frustration dealing with things that we all take for granted, simple tasks like tying your shoe lights or buttoning your shirt. That fine motor component can really be affected by this disorder.

Yeah, 100%.

When I was in medical school and in training, the treatments were limited mainly to medication, but there's been tremendous explosion in the research, whether it's looking at surgical interventions with deep brain stimulators, nutritional interventions, medications, and then the topic of today, the therapeutic approach through PT and rehabilitation. So that brings us to your certification in LSVT BIG. What is that?

So LSVT BIG, it originally stemmed from LSVT LOUD. The full name would be the Lee Silverman Voice Treatment. It originally began because there was a patient named Lee Silverman who had Parkinson's. Her family's main request was to be able to hear her better because oftentimes, people with Parkinson's, they tend to have more of a soft voice. They don't speak quite as loud, and so her family wanted to start to hear her better and then came along the LSVT LOUD program. That's where it stemmed from, and that's a program for speech therapists that they use with patients to help them speak louder and speak more clearly, and so after they saw the great results they got with LSVT LOUD, they decided to also make a program called LSVT BIG. That's for physical therapy and occupational therapists to use, and that's really looking more towards the motor function. So with big, we're looking at big movements and trying to fight the slowing and smallness of movements that you talked about.

Okay. So you evaluate patients in the clinic using this methodology, correct?

Correct. Correct. Yep.

Walk us through. If there's a prospective patient listening who's never heard of this, and let's say they're in their 40s or 50s and they're starting to have functional challenges, some stiffness developing and just fine motor and even just their gait. Walk someone through what an initial consultation with you would look like.

Sure. So on the initial consultation, we're just going to start by talking. So what I really want to know is just the patient's history, when they were first diagnosed with Parkinson's, what their initial symptoms were, and then what kinds of progressions of symptoms that they've noticed or any more recent symptoms that have come on, and then from there, we're really looking about their daily life. So are they on Parkinson's medications? What's their medication schedule? How are they responding to it? What's their home environment like? If they're working, what's their work environment like? Any troubles they may be having in their daily routine or in their exercise routine or their hobbies that they want to improve on, and once we get a good idea of that, we'll go into more of a physical evaluation. So looking at their walking, their balance, their strength, their flexibility, functional movements, maybe a transfer from standing up from the chair or lying down on the mat, anything that they may be having trouble with.

Once we take all those measurements, we'll look a little bit at some outcome measures, some standardized measurements that we can use to track progress along the way, so maybe that would be a walking speed test or a walking endurance test, and then from there, we'll talk about the program, decide if that's something that the patient would be interested in, and then we'll really decide what we want to work on in the program. So in the program, you're going to pick functional component tasks that you want to work on. Those are everyday things that you do. So that might be doing a button or typing on your phone, and then you'll pick hierarchy tasks, so that might be a big goal that you have like maybe going to a restaurant with your family or playing a round of golf and just make goals based on what's important to the patient, and then that's really how we'll formulate the program based on.

How does this approach differ from traditional physical therapy? What does it mean when it says LSVT BIG?

So the treatment protocol is a standardized program, so they've done a lot of research on it. The big component really comes from what the program is based on and it's main principles. So overall, the program is based on the principle of neuroplasticity. So for anyone who doesn't know what that is, that would be the ability of the nerve networks in your brain to change and reorganize in a way to change how you function. So it's like your brain rewiring to improve your functioning. So LSVT BIG, we're basing it on neuroplasticity and to get that neuroplasticity and make those rewiring connections, we're really looking at amplitude. So training larger movements, because like we talked about, people with Parkinson's tend to become small and they make all their movements slower and smaller. So we're going to get them to over exaggerate it.

We're going to get them to move really big, and while it might seem super exaggerated when we act it out, when they act it out, it's essentially going to be normal movement because they're starting from a place that's smaller. So having them do things that feel really exaggerated to them is going to look normal to us, and that's one of the main parts of the program. The other main part is that it's going to be really high effort. So we want to make it high intensity. We want the patient to feel like they're being challenged because that's how we're going to get the brain to adapt and change. Lastly, it's going to be something that's important to the patient like I talked about. That way, when they work on it in the clinic and then they can carry it over into their life, they notice the improvement, and when they notice that improvement, that's what we call being calibrated. So they notice that they made the change, they moved bigger, and they got to a place where they're moving more normally, and that's really the goal.

Okay. Let's unpack that a little bit. You touched on a phrase there, neuroplasticity, and that came up as well in my recent podcast with Dr. Gerry Stanley, where we dove into virtual reality and pain, and once again, we're utilizing the idea that we can, in one sense, regenerate or regrow neural networks and neural patterns in the brain when decades ago, the thought process wasn't possible. We know that's not true, particularly in the stroke rehab literature.

It almost sounds a little bit similar to when I was in residency, was when constraint induced movement therapy first came out for people with strokes where if you had a stroke and let's say it made your right arm weak and you couldn't move it, well, they would constrain your left arm and force you to use your right arm all the time as another way to stimulate that neuroplastic change and growth. I've never really thought about it in the context of Parkinson's until you just mentioned it, so that's very fascinating to me. I also like the component you talked about where you make it somewhat meaningful for the person and they can then better gauge the success.

Yes. Yeah.

Makes me wonder, perhaps we should be doing that for most of our treatments, because that's what brings people in. What bring people in is not that they have slow fine motor tasks. It's that they can't do something functional and therefore, it affects the quality of life.

Exactly.

So what does a path or protocol look like? Is this something that you'll see someone for a weekly, and what's a timeline and expectation of results for people?

So the program as it is standardized is going to be four consecutive days a week for four weeks. So it's 16 sessions total within that one month period.

Wow.

So that's where the high intensity comes from. So it's very much you're invested in it for that four weeks. Each session is 60 minutes, all one-on-one therapy throughout that 60 minutes. So we'll start with a warmup, something aerobic to get the heart rate up, and then we'll go into what the program calls the seven maximal daily exercises, and those are exercises that were specifically made for this program that work to combat the main symptoms of Parkinson's, so that forward flex posture, rigidity through the trunk, decreased arm swing, just things that are going to help fight that, so it's seven exercises that are already picked out so we can adapt them to the patient's needs, whether they can do them standing or sitting or even if they have to do them lying down, just we meet them where they are.

After we do those, we'll go into our functional component tasks, which I touched on a little bit earlier, but essentially, we'll pick five just everyday activities that the patient wants to improve on. So that could be putting on a jacket or typing on their phone or pulling keys out of their pocket, anything that they have to do just throughout the day that they know they can do better on, and it can be more gross motor too. It could be going up stairs or something like that, and then after that, we'll work on our hierarchy tasks, which are those very broad goals. I think the example I used earlier is somebody wanted to go to dinner with their family, so we break it down into parts.

So the first part of that might be getting dressed to go out to dinner. So we focus on getting dressed, and then maybe the second part is getting in and out of the car. So we're going to work on car transfers. The third part might be actually sitting at the table and using the utensils, which can be difficult because of hand tremors, so we're going to work on that, and then we're just going to build on that over the month so that we eventually have worked on the whole goal and they're able to go do that, and then we finish up with what we call big walking. We always work on walking and trying to normalize gait patterns.

It's going to be really big arm swing, big steps, really trying to get the patient moving and then scale it to a point where they're actually walking with normal gait pattern and normal gait mechanics. That should take up about the 60-minute session. Each day the patient gets a homework assignment that they work on for the rest of the day. So say they're going to go to the store that day. So their homework assignment might be that they're just going to focus on doing their big walking while they're walking through the grocery store or something like that, and then they come back the next day and we see how they did, and we start from the beginning.

That is really intensive up front. How does one transition that to home or with you? So they do the initial month. You said four times a week for an hour, and then is that stage one and then stage two, you taper down, or what's the follow through on that?

So each week, it'll be four days a week for the whole four weeks. What we want to do is progress the patient throughout the four weeks, so we're going to make things more difficult. So say they get the hang of it, they get the hang of the seven exercises the first week, and they're doing pretty well with it, well, on the next week, we might have them do it on a foam pad where their balance is challenged or with hand weights so that we make it a little bit harder, or we might increase the number of repetitions they're doing from 10 of each exercise to 15 of each exercise, so each week is a bit of a progression, so we get the patient to where they want to be by the end of it. So it is pretty intense. After the program is finished, after the patient completes the four weeks, they're going to work on a home exercise program.

So that will consist of the seven daily exercises at a level that's appropriate for them. They'll do that each day and then work on their walking each day. They can come back after a couple months for what we call a tune-up visit, where we just review everything, see how they're doing. There's also a program called LSVT BIG for LIFE that... It's a separate training course. I haven't took it yet, but it sounds interesting, so I might have to, but it's essentially a group class that people come to that have done the program for a way to ensure continued compliance, and they can do their exercises in a group setting, so it's more social, which could definitely be fun.

So do you find that after the four weeks, it creates a new baseline for these patients?

Absolutely. Yeah. Absolutely.

Yeah, that is just fascinating.

That's why it helps to take the outcome measures in the beginning, and we'll videotape their walking in the beginning, so then we can really see at the end what their new baseline is, and it can really be a significant improvement, which is really cool.

Oh, this is cool. We definitely have to get some of that video on our YouTube channel for CNSA. This is definitely worth sharing.

Definitely.

You mentioned earlier, one of the functional deficits is that rounded posture where they're slumped forward. For me, I feel like that's a big contributor to back pain.

Absolutely.

So have you found, as you work on that functional deficit, you'll see a correlation in pain reduction?

Definitely. With the exercises, especially those seven maximal daily exercises, we're really working on getting what we call BIG posture, so fighting that forwards posture, which can definitely contribute to back pain, because that's a lot of strain on the back, but if we can get them into that BIG posture, so shoulders back, getting the chest up, and then working on some of those rotational movements too through the thoracic spine to loosen up there, and then that overall just helps a ton with back mobility and decreasing back pain.

Are there any components of the program that deal with diaphragmatic breathing or their respiratory patterns?

Not specifically, but I'm sure that's something that we could work on if we needed to.

Yeah. It would just be interesting to see the influence of that. Yeah, I've been doing a lot of research recently on breath work and pain and understanding the attachments to the diaphragm and just the ability to take a deep breath and how it can be helpful for the nervous system. The other thing that could be really interesting if we want to geek out is I do a form of acupuncture called Chinese scalp acupuncture, where I'm actually putting needles on areas in the scalp that overly different disc cortical zones of function, so the motor strip, the sensory strip, and there's also some areas that can help with muscle tone and muscle spasm. It would be very interesting at some point, maybe we could do a treatment before a patient comes in to see you and see what type of results we can get with that. So certainly lots of opportunities to explore. This sounds like a fascinating offering for our practice and for the people in the community, and I'm very thankful that you've got your heart into it.

Oh, good. Thanks. Yeah, no, that sounds really cool. I would definitely be down to do that. That's awesome.

Yes, and there's also auricular acupuncture points which might even be easier to implement for people. So there's lots of things to work on. Anything else you want people to know who might be thinking about seeing you for this type of program?

We can see really good results. I would say one of the things that's most studied with it is walking speed. That's something that people with Parkinson's tend to have a lot of trouble with, so there's really good studies just on improvement in walking speed after the LSVT BIG program. Also, just balance outcome measurements, and another thing that I thought was interesting was dual tasking. So if you are throwing somebody a walking physical task, asking them to do a mental task, with people with Parkinson's, that's going to be super hard because anytime that you're adding more stress to the system, it's going to really challenge that dopamine in their brain and you're going to see more physical symptoms when they're having to multitask. I see that all the time in the clinic. If I'm asking a patient to do an exercise and then I ask them about their day and what they're doing later, they'll immediately... Their hand tremor will pick up. They'll get a little unstable.

Wow.

So it's really interesting and studies on the LSVT BIG program show that it can help improve with that dual tasking ability too, which I think is cool.

Well, it sounds like it could have far-reaching effects from a quality of life perspective. I look forward to hearing more from you as you expand the program and have more people enrolled in it, and we can definitely track... I love that you're tracking the data on it too. That's something that can potentially, through the group, be published. So before I let you go, doing this type of work takes energy and effort on your part, and I'd love to pick your brain as I do everyone on the show about their own self health measures and interventions and podcasts and books, whatever you want to share with people that you think is important for just your general health and fitness.

Sure. So I have always been somebody who's very into nutrition and healthy cooking and healthy eating. During COVID, I actually started an Instagram blog on just healthy cooking and recipes and things like that, so that's something that's really important to me, and if anybody is in need of some fun recipes or just good healthy eating tips, dive in on Instagram or really any social media outlet because you can find a ton of really good healthy recipes on there. Also, as far as fitness, I'm really into Pilates. That's something that I've actually gotten into since working at CNSA because that's something that we really use in physical therapy with our patients with back pain, is Pilates based core strengthening, because we all know that deep abdominal strength is so important, so you can find me in a Pilates class a couple times a week trying to keep on that, but it's really fun. I really enjoy it.

Oh, that's great. So how can people find you on IG if they want some recipes?

My Instagram is @stiritupwithsam.

Oh, I love it.

But yeah, there's a ton of good accounts out there, so once you start to find one, then they're all going to start popping up, so you really can't go wrong.

Yeah, that's great, and the Pilates thing is really interesting. I feel like Pilates is almost like graduate school from PT. So I'll have people that come in with back injuries and I'll recommend some PT and they'll say, "Well, can I just do a Pilates video?" My answer is no, but once you're feeling great, then you can transition and learn more about it probably from a certified teacher and make that your go-to. Now, there's not tremendous research either way on Pilates and even yoga. There's limited small scale studies on this for back pain. My clinical experience has been I tend to recommend or prefer Pilates over yoga just so we're not having the deep extreme flexion, downward facing dog, the extreme positions that can get people in trouble. Plus Pilates definitely has a strengthening component that I feel like is beneficial for people. I'm glad to hear you practice what you preach though.

Yeah, I try.

All right. Well, I definitely enjoyed the interview. I look forward to checking out your recipes for sure-

Thank you.

... and let's definitely do a follow-up down the road when we have some more success stories to share about the patients coming to see you.

Yeah, that sounds great. Thank you so much for having me. This was a good time.

All right, Sam. Yeah. Thank you for your time.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.