On “Application of LSVT BIG intervention…” Janssens J, Malfroid KN, Myffeler T, et al. Phys Ther. 2014;94:1014–1023.

We would like to congratulate Janssens et al on their case report¹ published in the July 2014 issue of PTJ. Their findings are important in that following application of LSVT BIG^® treatment to 3 individuals with Parkinson disease (PD), they demonstrated clinically significant improvements in gait, balance, and bed mobility through their standardized outcome assessments. In addition, their documentation of the more than 5-point drop (5.6) in the Unified Parkinson's Disease Rating Scale motor score is consistent with that previously documented by Ebersbach et al² in the LSVT BIG Berlin study. As LSVT BIG certified clinicians and LSVT Global Inc faculty members, we observe similar changes consistently in our patients with PD following LSVT BIG. This work of Janssen and colleagues supports the positive effect of LSVT BIG on improving the deficits of bradykinesia and hypokinesia.

We are writing this letter because the published description of the LSVT BIG treatment protocol is missing a number of key components. Through consultation with the authors, it was determined that these key components were actually completed as part of the protocol but were not included in the published article due to space limitations within tables. As a result, we are writing to clarify those key components for the readers and to direct readers to the article by Fox et al³ for a full description and details of the LSVT BIG protocol, which is briefly outlined below.

The LSVT BIG protocol consists of completion of:

• 7 maximal daily exercises (2 sustained and 5 repetitive movements)

• functional component tasks

• BIG walking

• 1–3 hierarchy tasks

As shown in Table 3 of the case series, participants appeared to complete only 1 to 4 functional component tasks during the 4 weeks of treatment. In the LSVT BIG protocol, patients must complete 5 of these tasks, and all 5 tasks are completed repetitively from day 1 of treatment and on every treatment day throughout the 16 treatment sessions.

The published report of the LSVT BIG protocol includes no documentation of hierarchy tasks. Hierarchy tasks are complex, salient functional tasks that also are practiced repetitively and are important for carryover of amplitude re-scaling into everyday life.

Throughout delivery of the LSVT BIG protocol, we work with the patient to select functional components and hierarchies that are salient to that particular patient. The high number of repetitions of practice is important to drive neuroplasticity, which is why it is critical that all areas of treatment be initiated from day 1.

We look forward to further research by this group on this topic.

• © 2014 American Physical Therapy Association