Lee Silverman Voice Treatment BIG® Method for Parkinson's Disease
Health Problem : Risk of fall
Designation
Lee Silverman Voice Treatment BIG® Method for Parkinson's Disease
Abbreviation
LSVT BIG®
Category
Bodily
Main Indication
Develop broader, faster, and more functional movements.
How does it work?
Intensive rehabilitation method that reduces movement slowness, difficulty in initiating movement, and improves the range of motion.
Other Benefits
- Significant improvement in walking speed.
- Improvement in posture and the ability to maintain balance.
- Improvement in hand dexterity.
- Improvement in breathing.
- Reduction in fear of falling.
- Improvement in quality of life.
Direct Risks
- This NPI is well tolerated in general.
- Risks of temporary fatigue and mild muscle pain.
- Rare risk of falls during intense exercises.
- Rare worsening of involuntary movements in some patients.
Risks of interaction
The risks of interaction with medications are unknown.
Target Audience
People with Parkinson's disease at all stages, including early and moderate stages.
Contraindications
- Person with severe cognitive disorders.
- Person with uncontrolled psychiatric disorders making participation impossible.
Duration
4 weeks
Sessions per week
4 supervized sessions
Precautions
The practitioner will ensure that the environment is safe to prevent falls.
They will monitor fatigue and acute pain, as well as severe orthostatic instability. They will adapt exercises in case of health problems (osteoarthritis, heart issues) and monitor any cardiorespiratory decompensation.
The session will be canceled in case of infection.
The treatment can be adapted in consultation with the neurologist if necessary.
Ensure the absence of recent fractures or disabling joint or postural problems.
They will monitor fatigue and acute pain, as well as severe orthostatic instability. They will adapt exercises in case of health problems (osteoarthritis, heart issues) and monitor any cardiorespiratory decompensation.
The session will be canceled in case of infection.
The treatment can be adapted in consultation with the neurologist if necessary.
Ensure the absence of recent fractures or disabling joint or postural problems.
Regulatory provisions
On medical prescription according to the regulations in force in the country.
Main Initiator
Lorraine Ramig, Cynthia Fox, Lee Silverman Voice : https://www.lsvtglobal.com/
Author(s) of the Sheet
NPIS (comité scientifique)
Creation Date : 12/03/2026
Revision Date : 14/04/2026
Version : V01
Revision Date : 14/04/2026
Version : V01
Download the sheet in PDF format
Designation
Lee Silverman Voice Treatment BIG® Method for Parkinson's Disease
Abbreviation
LSVT BIG®
Category
Bodily
Main Health benefit
- Develop broader, faster, and more functional movements.
- ICD 11 : 8400.0
Explanation
Intensive rehabilitation method reducing bradykinesia (slowness of movement), hypokinesia (reduction in movement amplitude), and akinesia (difficulty initiating movement) (Ebersbach 2010; Fox 2012; Choi 2022; Kaya Aytutuldu 2024; Doucet 2025).
Routine Test
Part III, called the motor part of the Unified Parkinson's Disease Rating Scale or UPDRS (Shulman, 2010).
Threshold
A score below 20–25 points on part III of the UPDRS corresponds to a mild stage of severity, between 25 and 40 to a moderate stage, and above 40 to a severe stage.
Minimal Clinically Important Change
The Minimal Clinically Important Difference or MCID for Part III of the UPDRS is estimated at 3 to 4 points for an improvement, and 4 to 5 points for a deterioration (Shulman, 2010).
Secondary benefits
- Significant improvement in walking speed (Fox 2012).
- Improvement in posture and balance (McDonnell 2018; Matsuno 2023; Ernst 2023).
- Improvement in manual dexterity (Fox 2012).
- Improvement in breathing (Fox 2012).
- Reduction in fear of falling (Ebersbach 2015).
- Improvement in quality of life (Hirakawa 2021; Choi 2022).
Direct Risks
- This NPI is well tolerated in general.
- Risks of temporary fatigue and mild muscle pain.
- Rare risk of falls during intense exercises.
- Rare worsening of dyskinesias in some patients.
Risks of interaction
The risks of interaction with medications are unknown.
Biological and Psychosocial Mechanisms
Improvement of brain neuroplasticity (Peterka 2020)
Intervention uses high-intensity repetition and large-amplitude movements to engage residual motor circuits and promote cortico-subcortical reorganization. This principle of intensive training is at the core of functional recovery in neurology.
Rehabilitation of the dopaminergic system (Won 2025)
The LSVT BIG method does not restore dead dopaminergic neurons but optimizes the use and regulation of residual dopaminergic circuits through neuroplasticity and functional reorganization.
Improvement and recalibration of proprioception (Peterka 2020)
Patients often have an altered perception of the amplitude of their movements. LSVT BIG® provides repeated external and internal feedback that readjusts proprioceptive perception, allowing effective increase in movement amplitude and improvement in motor precision.
Improvement of motor control and coordination (McDonnell 2018) Through targeted work on amplitude, speed, and synchronization (arms-legs, trunk), the program strengthens voluntary motor patterns, reduces bradykinesia, and improves intersegmental coordination, resulting in better walking speed and step length. NPI teaches the patient to 'think big': this constant cognitive cue modifies the mental representation of the movement and promotes the conscious application of larger movements in daily life, facilitating the transfer of gains from therapy sessions to daily activities.
Improvement of posture and balance (Matsuno 2023; Eldemir 2024)
Overall training (upper limbs, lower limbs, trunk) and repetition of functional tasks increase functional strength, exercise tolerance, and dynamic stability, contributing to a relative reduction in motor limitations. Automation and generalization Given the impairment of procedural memory related to Parkinson's syndrome, through repetition and practice of functional tasks, new motor patterns tend to become automated, reducing dependence on supervision and allowing integration into daily activities.
Increase in self-confidence and motivation (Farley 2005)
High intensity, frequent feedback, and measurable goals enhance the patient's motivation and confidence. The increase in self-efficacy promotes adherence to home exercises, a crucial condition for maintaining the effects.
Reduction of fear of falling (Ebersbach 2015)
Intervention uses high-intensity repetition and large-amplitude movements to engage residual motor circuits and promote cortico-subcortical reorganization. This principle of intensive training is at the core of functional recovery in neurology.
Rehabilitation of the dopaminergic system (Won 2025)
The LSVT BIG method does not restore dead dopaminergic neurons but optimizes the use and regulation of residual dopaminergic circuits through neuroplasticity and functional reorganization.
Improvement and recalibration of proprioception (Peterka 2020)
Patients often have an altered perception of the amplitude of their movements. LSVT BIG® provides repeated external and internal feedback that readjusts proprioceptive perception, allowing effective increase in movement amplitude and improvement in motor precision.
Improvement of motor control and coordination (McDonnell 2018) Through targeted work on amplitude, speed, and synchronization (arms-legs, trunk), the program strengthens voluntary motor patterns, reduces bradykinesia, and improves intersegmental coordination, resulting in better walking speed and step length. NPI teaches the patient to 'think big': this constant cognitive cue modifies the mental representation of the movement and promotes the conscious application of larger movements in daily life, facilitating the transfer of gains from therapy sessions to daily activities.
Improvement of posture and balance (Matsuno 2023; Eldemir 2024)
Overall training (upper limbs, lower limbs, trunk) and repetition of functional tasks increase functional strength, exercise tolerance, and dynamic stability, contributing to a relative reduction in motor limitations. Automation and generalization Given the impairment of procedural memory related to Parkinson's syndrome, through repetition and practice of functional tasks, new motor patterns tend to become automated, reducing dependence on supervision and allowing integration into daily activities.
Increase in self-confidence and motivation (Farley 2005)
High intensity, frequent feedback, and measurable goals enhance the patient's motivation and confidence. The increase in self-efficacy promotes adherence to home exercises, a crucial condition for maintaining the effects.
Reduction of fear of falling (Ebersbach 2015)
Responding population
People with Parkinson's disease at all stages, including early and moderate stages.
Nonresponding population
- Person with severe cognitive disorders.
- Person with uncontrolled psychiatric disorders making participation impossible.
Participants
Individual
Duration
4 weeks
Sessions per week
4 supervized sessions
Procedure
The patient follows a 16-session program supervised by a physiotherapist trained in the method (Doucet 2021). It includes intensive exercises based on large-amplitude movements of the whole body in a seated position at a brisk pace, multidirectional standing exercises such as lunges and reaching targets, and functional exercises. These are complemented by practicing large-amplitude gestures to integrate into daily life (such as getting up from a seated position to stand, performed with the same large-amplitude target). To encourage regular practice of exercises at home, patients are asked to keep a daily activity diary.
Week 1: Learning the basic exercises, implementing recalibration (slow execution then increasing amplitude).
Week 2: Increasing repetitions and speed, integrating simple functional tasks.
Week 3: Complexification with sequences and dual-tasks (Isaacson 2018) and work on walking (large steps, arm swinging).
Week 4: Consolidation, automatization of large movements, and a home maintenance program to maintain the gains.
Week 1: Learning the basic exercises, implementing recalibration (slow execution then increasing amplitude).
Week 2: Increasing repetitions and speed, integrating simple functional tasks.
Week 3: Complexification with sequences and dual-tasks (Isaacson 2018) and work on walking (large steps, arm swinging).
Week 4: Consolidation, automatization of large movements, and a home maintenance program to maintain the gains.
Components
Each session is intense and repetitive. It focuses on the range of motion. The exercises are personalized and progressive. Participants are encouraged to practice the exercises at home daily (Janssens 2014). Attention to the perception of movements is used to correct motor disturbances that result from sensorimotor disorders related to Parkinson's disease.
The LSVT BIG® method trains the patient to master the parameter amplitude which is coupled with the recalibration of sensorimotor integration.
The LSVT BIG® method trains the patient to master the parameter amplitude which is coupled with the recalibration of sensorimotor integration.
- Large-amplitude movements: The exercises are performed deliberately exaggerated (big steps, wide gestures) to compensate for the natural tendency to reduce amplitude.
- High intensity and sustained effort: The sessions are dynamic and require significant physical engagement.
- Varied exercises: global motor activities (getting up from a chair, walking with big steps…) and fine motor activities (buttoning a shirt, writing…) with integration for daily life gestures.
Equipment
- Stable chair without armrests.
- Non-slip mat.
- Cones or markers on the floor.
- Stopwatch.
- Small objects for grasping (buttons, cup…).
- Tracking notebook for the patient.
Location
Physiotherapy office, rehabilitation center.
Best implementation practices
- Start with a 5-minute warm-up.
- Begin with reduced ranges and durations, then gradually increase the load and complexity under supervision.
- Encourage active participation.
- Use personalized feedback with MCID (Millage 2017).
- Provide consistent feedback on performance.
- Integrate functional exercises relevant to daily life.
Best practices for sustainability
- Encourage the regular practice of exercises at home after the end of the intensive program.
- Offer follow-up sessions.
- Integrate the principles of LSVT BIG® into daily activities.
Precautions
Ensure that the environment is safe to prevent falls.
Monitor fatigue and acute pain.
Monitor severe orthostatic instability.
Adapt exercises in case of comorbidities (osteoarthritis, heart problems).
Monitor any cardiorespiratory decompensation.
Cancel the session in case of an infectious condition.
Consultation with the neurologist is useful in case of motor fluctuations or dyskinesias to adjust medication treatment if necessary.
Ensure the absence of recent fractures or disabling joint or postural problems.
Monitor fatigue and acute pain.
Monitor severe orthostatic instability.
Adapt exercises in case of comorbidities (osteoarthritis, heart problems).
Monitor any cardiorespiratory decompensation.
Cancel the session in case of an infectious condition.
Consultation with the neurologist is useful in case of motor fluctuations or dyskinesias to adjust medication treatment if necessary.
Ensure the absence of recent fractures or disabling joint or postural problems.
Regulatory specification
On medical prescription according to the regulations in force in the country.
Main Initiator
Lorraine Ramig, Cynthia Fox, Lee Silverman Voice : https://www.lsvtglobal.com/
Qualification required
Physiotherapist certified LSVT BIG®. https://www.lsvtglobal.com/
References
Prototype study
Fox C et al. LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinsons Dis. 2012;2012:391946. https://dx.doi.org/10.1155/2012/391946
Mechanistic study
Peterka M, Odorfer T, Schwab M, Volkmann J, Zeller D. LSVT-BIG therapy in Parkinson's disease: physiological evidence for proprioceptive recalibration. BMC Neurol. 2020 Jul 11;20(1):276. https://dx.doi.org/10.1186/s12883-020-01858-2
Interventional studies
Ebersbach G et al. Amplitude-oriented exercise in Parkinson's disease: a randomized study comparing LSVT-BIG and a short training protocol. J Neural Transm (Vienna). 2015 Feb;122(2):253-6. https://dx.doi.org/10.1007/s00702-014-1245-8
Choi Y et al. Effects of Task-Based LSVT-BIG Intervention on Hand Function, Activity of Daily Living, Psychological Function, and Quality of Life in Parkinson's Disease: A Randomized Control Trial. Occup Ther Int. 2022 Sep 10;2022:1700306. https://dx.doi.org/10.1155/2022/1700306
Implementation study
Janssens J et al. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with Parkinson disease: a case series. Phys Ther. 2014 Jul;94(7):1014-23. https://dx.doi.org/10.2522/ptj.20130232
Other publications
Doucet BM et al. Occupational Performance and Hand Function in People With Parkinson's Disease After Participation in Lee Silverman Voice Treatment (LSVT) BIG®. Am J Occup Ther. 2021 Nov 1;75(6):7506205010. https://dx.doi.org/10.5014/ajot.2021.042101
Doucet BM, Blanchard M, Franc I. Effects of LSVT BIG® on Bradykinesia During Activities of Daily Living. OTJR (Thorofare N J). 2025 Sep 19:15394492251367275. https://dx.doi.org/10.1177/15394492251367275
Ebersbach G et al. Comparing exercise in Parkinson's disease--the Berlin LSVT®BIG study. Mov Disord. 2010 Sep 15;25(12):1902-8. https://dx.doi.org/10.1002/mds.23212
Eldemir S et al. The effects of standard and modified LSVT BIG therapy protocols on balance and gait in Parkinson's disease: A randomized controlled trial. Brain Behav. 2024 Mar;14(3):e3458. https://dx.doi.org/10.1002/brb3.3458
Ernst M et al. Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis. Cochrane Database Syst Rev. 2023 Jan 5;1(1):CD013856. https://dx.doi.org/10.1002/14651858.CD013856.pub2
Hirakawa Y et al. Effect of Lee Silverman Voice Treatment (LSVT)® BIG on motor symptoms in a patient with severe Parkinson's disease: a case report. Physiother Theory Pract. 2022 Nov;38(13):3159-3168. https://dx.doi.org/10.1080/09593985.2021.1938304
Hirakawa Y et al. Short-term effect and its retention of LSVT® BIG on QOL improvement: 1-year follow-up in a patient with Parkinson's disease. NeuroRehabilitation. 2021;49(3):501-509. https://dx.doi.org/10.3233/NRE-210129
Isaacson S et al. The JFK BIG study: the impact of LSVT BIG® on dual task walking and mobility in persons with Parkinson's disease. J Phys Ther Sci. 2018 Apr;30(4):636-641. https://dx.doi.org/10.1589/jpts.30.636
Kaya Aytutuldu G et al. LSVT® BIG versus progressive structured mobility training through synchronous telerehabilitation in Parkinson's disease: A randomized controlled trial. Neurol Sci. 2024 Jul;45(7):3163-3172. https://dx.doi.org/10.1007/s10072-024-07322-0
Matsuno A et al. Quantitative assessment of the gait improvement effect of LSVT BIG® using a wearable sensor in patients with Parkinson's disease. Heliyon. 2023 Jun 3;9(6):e16952. https://dx.doi.org/10.1016/j.heliyon.2023.e16952
McDonnell MN at al. Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil. 2018 May;32(5):607-618. https://dx.doi.org/10.1177/0269215517734385
Millage B 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;2017:9871070. https://dx.doi.org/10.1155/2017/9871070
National Institute for Health and Care Excellence (NICE). Parkinson's disease in adults: diagnosis and management. NICE guideline, NG71, 2017 https://www.nice.org.uk/guidance/ng71/chapter/Recommendations#non-pharmacological-management-of-motor-and-non-motor-symptoms
Shulman LM et al. The clinically important difference on the unified Parkinson's disease rating scale. Arch Neurol. 2010 Jan;67(1):64-70. https://dx.doi.org/10.1001/archneurol.2009.295
Won C et al. Effectiveness of Lee Silverman Voice Treatment (LSVT)-BIG for Neurological Diseases Other than Parkinson's Disease: Mini Review. Brain Sci. 2025 Mar 31;15(4):367. https://dx.doi.org/10.3390/brainsci150403https://dx.doi.org/10.3390/brainsci1504036767
Fox C et al. LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinsons Dis. 2012;2012:391946. https://dx.doi.org/10.1155/2012/391946
Mechanistic study
Peterka M, Odorfer T, Schwab M, Volkmann J, Zeller D. LSVT-BIG therapy in Parkinson's disease: physiological evidence for proprioceptive recalibration. BMC Neurol. 2020 Jul 11;20(1):276. https://dx.doi.org/10.1186/s12883-020-01858-2
Interventional studies
Ebersbach G et al. Amplitude-oriented exercise in Parkinson's disease: a randomized study comparing LSVT-BIG and a short training protocol. J Neural Transm (Vienna). 2015 Feb;122(2):253-6. https://dx.doi.org/10.1007/s00702-014-1245-8
Choi Y et al. Effects of Task-Based LSVT-BIG Intervention on Hand Function, Activity of Daily Living, Psychological Function, and Quality of Life in Parkinson's Disease: A Randomized Control Trial. Occup Ther Int. 2022 Sep 10;2022:1700306. https://dx.doi.org/10.1155/2022/1700306
Implementation study
Janssens J et al. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with Parkinson disease: a case series. Phys Ther. 2014 Jul;94(7):1014-23. https://dx.doi.org/10.2522/ptj.20130232
Other publications
Doucet BM et al. Occupational Performance and Hand Function in People With Parkinson's Disease After Participation in Lee Silverman Voice Treatment (LSVT) BIG®. Am J Occup Ther. 2021 Nov 1;75(6):7506205010. https://dx.doi.org/10.5014/ajot.2021.042101
Doucet BM, Blanchard M, Franc I. Effects of LSVT BIG® on Bradykinesia During Activities of Daily Living. OTJR (Thorofare N J). 2025 Sep 19:15394492251367275. https://dx.doi.org/10.1177/15394492251367275
Ebersbach G et al. Comparing exercise in Parkinson's disease--the Berlin LSVT®BIG study. Mov Disord. 2010 Sep 15;25(12):1902-8. https://dx.doi.org/10.1002/mds.23212
Eldemir S et al. The effects of standard and modified LSVT BIG therapy protocols on balance and gait in Parkinson's disease: A randomized controlled trial. Brain Behav. 2024 Mar;14(3):e3458. https://dx.doi.org/10.1002/brb3.3458
Ernst M et al. Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis. Cochrane Database Syst Rev. 2023 Jan 5;1(1):CD013856. https://dx.doi.org/10.1002/14651858.CD013856.pub2
Hirakawa Y et al. Effect of Lee Silverman Voice Treatment (LSVT)® BIG on motor symptoms in a patient with severe Parkinson's disease: a case report. Physiother Theory Pract. 2022 Nov;38(13):3159-3168. https://dx.doi.org/10.1080/09593985.2021.1938304
Hirakawa Y et al. Short-term effect and its retention of LSVT® BIG on QOL improvement: 1-year follow-up in a patient with Parkinson's disease. NeuroRehabilitation. 2021;49(3):501-509. https://dx.doi.org/10.3233/NRE-210129
Isaacson S et al. The JFK BIG study: the impact of LSVT BIG® on dual task walking and mobility in persons with Parkinson's disease. J Phys Ther Sci. 2018 Apr;30(4):636-641. https://dx.doi.org/10.1589/jpts.30.636
Kaya Aytutuldu G et al. LSVT® BIG versus progressive structured mobility training through synchronous telerehabilitation in Parkinson's disease: A randomized controlled trial. Neurol Sci. 2024 Jul;45(7):3163-3172. https://dx.doi.org/10.1007/s10072-024-07322-0
Matsuno A et al. Quantitative assessment of the gait improvement effect of LSVT BIG® using a wearable sensor in patients with Parkinson's disease. Heliyon. 2023 Jun 3;9(6):e16952. https://dx.doi.org/10.1016/j.heliyon.2023.e16952
McDonnell MN at al. Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil. 2018 May;32(5):607-618. https://dx.doi.org/10.1177/0269215517734385
Millage B 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;2017:9871070. https://dx.doi.org/10.1155/2017/9871070
National Institute for Health and Care Excellence (NICE). Parkinson's disease in adults: diagnosis and management. NICE guideline, NG71, 2017 https://www.nice.org.uk/guidance/ng71/chapter/Recommendations#non-pharmacological-management-of-motor-and-non-motor-symptoms
Shulman LM et al. The clinically important difference on the unified Parkinson's disease rating scale. Arch Neurol. 2010 Jan;67(1):64-70. https://dx.doi.org/10.1001/archneurol.2009.295
Won C et al. Effectiveness of Lee Silverman Voice Treatment (LSVT)-BIG for Neurological Diseases Other than Parkinson's Disease: Mini Review. Brain Sci. 2025 Mar 31;15(4):367. https://dx.doi.org/10.3390/brainsci150403https://dx.doi.org/10.3390/brainsci1504036767
Experts who voted for the publication of this sheet
FRANCO Gianni , NINOT Grégory , HERBINET AlineAuthor(s) of the Sheet
NPIS (comité scientifique)
Creation Date : 12/03/2026
Revision Date : 14/04/2026
Version : V01
Revision Date : 14/04/2026
Version : V01
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