Bigger Movements - Better Quality of Life: Parkinson's Case Study

Original Editor - Sue Klappa

Title

Bigger Movements - Better Quality of Life: Parkinsons Disease Case Study

Abstract

“Mr. Johnson” is a 67-year-old patient with Parkinson’s disease (PD), a progressive, incurable disorder where dopamine level is decreased due to the death of the dopaminergic neurons in the substantia nigra and basal ganglia causing the patient to develop motor and non-motor symptoms. These symptoms included: freezing, slow initiation of movements with unwanted acceleration and difficultly stopping, shuffling gait, quiet and slow speech, resting tremor, decreased dexterity and facial expression, as well as confusion and rigidity. This case will discuss PD and how to address symptoms with physical therapy in combination with medications as prescribe by the treating physician.

Keywords

Parkinson’s Disease, Physiotherapy, LSVT BIG Treatment

Client Characteristics

Mr. Johnson was an elementary school principle and has been retired for seven years. He lives with his wife, a 51-year-old full-time elementary school teacher. Together they have seven children. His hobbies include playing the piano, gardening, yard work, grocery shopping and cooking. He also walks an estimated one-mile around his pool every morning, while dropping sticks into target areas. Mr. Johnson was diagnosed with PD two years ago. Mrs. Johnson initially noticed symptoms of right foot drop and bilateral hand tremors in her husband. He was initially referred to physical therapy (PT) for evaluation and treatment in need of assistance with transfers and gait, difficulty speaking which was secondary to pooling of saliva, drooling, and diminished voice volume. He occasionally is incontinent due to inability to reach the bathroom in time. Mr. Johnson was initially given Sinement for his PD but was switched to Sinement CR with Calan SR due to increased blood pressure. Mr. Johnson is being considered for new trial medication with Eldepryl and his primary physician wants to add Artane to his treatment plan. Mrs. Johnson heard about Lee Silverman Voice Therapy (LSVT) and was hoping it would help her husband.

Examination findings

Neuromuscular Systems Review

Patient was alert and oriented to place and time, indicating that his cognitive function is at an acceptable level; no history of falls. Patient reports on/off phenomena and a resting tremor that is worse in the morning. Mr. Johnson’s bradykinesia is a primary problem causing incontinence, preventing him from wanting to leave the house, and he was slow in his ADLs.

PROM is within normal limits (WNL) with exception of: the Thomas test which is lacking 15 degrees bilaterally, SLR was 40 degrees, DF was -5 and +5 on his right and left side respectfully. AROM is limited in his axial, upper thoracic, hip and knee extension (-20 degrees). Patient lacks shoulder elevation (-60 degrees bilaterally) and ankle DF (-10 degrees bilaterally). Patient has a kyphotic posture with a forward head. He also rises from a chair by pulling himself forward and walks with a mild degree of festinating gait without distinct right heel contact. Tone is grossly WNL but does exhibit resistance in many muscles groups to PROM on the first motion. The pendulum test for rigidity was included.

Cardiopulmonary health is relatively good for his age, he walks around his pool and has a multitude of hobbies. Due to Mr. Johnson’s foot drop, doing a stress test on a stationary bike would be safer than on a treadmill. The therapist should examine his rib cage compliance, chest wall mobility and thoracic expansion during this test. Other options include: visual inspection of breathing patterns, ventilation parameters (respiratory rate, minute ventilation and inspiratory time), and vital signs (heart rate and blood pressure).

Since Mr. Johnson’s integumentary system did not present with pressure ulcers and will be intact. However, the therapist should still examine the patient for any bruising or skin breakdown.

Short Term Goals:

1. Patient will incorporating concepts of Lee Silverman Voice Treatment BIG, to improve postural set for gait, balance, and independent transfers within 6 visits.
2. Patient will increase core stability and strength through mirror training to reduce kyphotic posture to WNL of postural set within 6 visits to reduce the risk for falls.
3. Patient will increase range of motion and strength for bilateral dorsiflexion through active proprioceptive neuromuscular facilitation pattern exercises to within normal limits, bilaterally, within 6 visits for improved foot clearance during swing phase of gait.

Clinical Hypothesis

Parkinson’s disease is classified under practice pattern 5E (Impaired motor function and sensory integrity associated with progressive disorders of the central nervous system) within the Guide to PT Practice.3 PD progresses slowly with about a five-year subclinical period. In a study done by Feigin and Eidelberg, nine percent of patients became severely disabled or died within five years of diagnosis, twenty-one percent within 10 years, and thirty-seven percent within 15 years when taking L-dopa. Patients who have a young age onset PD or who are tremor predominant, typically have a better prognosis than those who do not. Those with postural instability and gait disturbances tend to have an even less favorable prognosis. Mortality is usually due to cardiovascular disease or pneumonia.2 It is reported, sixty percent of patients with Parkinson’s disease fall each year due to cognitive and attention deficits. The treatment Mr. Johnson will participate in, including strengthening and gait and balance training, will help him practice focusing on a task and provide him with physical practice and lead to improvement. With these factors one could give Mr. Johnson a moderately good prognosis, especially since he is taking L-dopa medications.

Intervention

Plan of Care

Management of the cardiopulmonary system will include a treadmill-training regimen to build up endurance and promote a healthy cardiovascular system. It provides an external cue to improve gait function in those patients with PD. Secondary outcomes included increased cadence, and walking distance. Mr. Johnson will undergo treadmill training sessions three times per week for four weeks, consisting of 15-minute interventions.

Management of the Musculoskeletal System and Neurological System will include generalized strengthening, PROM, AROM, and generalized stretching, as well as the Lee Silverman Voice Therapy BIG training. LSVT has been established as a treatment for speech and voice disorders in individuals with PD and has documented amazing success. LSVT uses intensive practice of high effort/large amplitude arm movements while focusing on sensory awareness of movement bigness. Extensive practice in LSVT and feedback/knowledge of results to teach patients with PD the amount of effort needed to consistently project an appropriate volume of voice. LSVT is administered in a manner consistent with an exercise program, with most patients going to four sessions a week for a scheduled four weeks, totaling 16 visits.9

Weeks 1-4

Treatment Monday Tuesday Thursday Friday
LSVT & LSVT BIG 1 hour 1 hour 1 Hour 1 Hour
Treadmill Training 30 minutes 30 minutes 30 minutes 30 minutes
PROM all extremities 15 minutes 15 minutes 15 minutes 15 minutes
General Strengthening* 15 minutes 15 minutes 15 minutes 15 minutes
*Strengthening will include PNF patterns in all extremities to facilitate full body involvement.*

Weeks 4-8

Treatment Monday Tuesday Thursday Friday
Generalized Strengthening* 15 minutes 15 minutes 15 minutes 15 minutes
Generalized Stretching* 15 minutes 15 minutes 15 minutes 15 minutes
AROM 10 minutes 10 minutes 10 minutes 10 minutes
Gait Training 30 minutes 30 minutes 30 minutes 30 minutes
*Generalized stretching and strengthening target the goal of total body movement and functional ability. Specific movements will be selected at the discretion of the Physical Therapist.*

Outcomes

An all-inclusive outcome measure for PD is Movement Disorder Society-Unified PD Rating Scale (MDS-UPDRS). The rating scale, for this measure is broken down into four different parts which include: non-motor experiences of daily living, motor experiences of daily living, motor examination, and motor complications. Both the rater and the patient or caregiver fill it out. Most sections have a rating scale of zero to four, zero being no impairment/symptoms and four being severe impairment/symptoms while others are yes/no questions.
The Hoehn and Yahr Scale included in An all-inclusive outcome measure for PD is Movement Disorder Society-Unified PD Rating Scale (MDS-UPDRS). The rating scale, for this measure is broken down into four different parts which include: non-motor experiences of daily living, motor experiences of daily living, motor examination, and motor complications. Both the rater and the patient or caregiver fill it out. Most sections have a rating scale of zero to four, zero being no impairment/symptoms and four being severe impairment/symptoms while others are yes/no questions.

The Hoehn and Yahr Scale included in MDS-UPDRS assesses the five stages of PD in terms of amount of disability in a patient. Stage I is “unilateral involvement only with minimal or no functional impairment” and it progresses up to stage V which is “confinement to bed or wheelchair unless aided.”Mr. Johnson was at Stage II because he has not yet progressed to losing his balance or having impaired righting reflexes, however, he had bilateral involvement as seen in his speech abnormalities, soft voice, slurring, kyphotic and forward head posture, and generalized slowness in ADL.

A quality of life outcome measure such as the PD Questionnaire (PDQ-39) could be used to evaluate bradykinesia on his toileting complications. This measure looks at 39 items of eight domains: “mobility, ADL, emotional well-being, stigma, social support, cognition, communication and bodily discomfort.” The multi-dimensional measure has proven to have good internal and test-retest reliability, as well as good face and construct validity

MDS-UPDRS assesses the five stages of PD in terms of amount of disability in a patient. Stage I is “unilateral involvement only with minimal or no functional impairment” and it progresses up to stage V which is “confinement to bed or wheelchair unless aided.” Mr. Johnson was at Stage II because he has not yet progressed to losing his balance or having impaired righting reflexes, however, he had bilateral involvement as seen in his speech abnormalities, soft voice, slurring, kyphotic and forward head posture, and generalized slowness in ADL.

A quality of life outcome measure such as the PD Questionnaire (PDQ-39) could be used to evaluate bradykinesia on his toileting complications. This measure looks at 39 items of eight domains: “mobility, ADL, emotional well-being, stigma, social support, cognition, communication and bodily discomfort.” The multi-dimensional measure has proven to have good internal and test-retest reliability, as well as good face and construct validity

Discussion

In conclusion, Parkinson’s is a manageable disease, to a point, when the use of medication and PT are utilized effectively. Medication helps to slow the progression of the disease and decrease the amplitude of the vast symptoms. Physical Therapy can be used to keep these patients active and functioning at a level much higher that what they would without any intervention and thus their quality of life can be greatly improved. The LSVT Loud and BIG protocols have been proven very effective in giving patients with PD more confidence in themselves due to clearer, louder volumes of voice and much larger, smoother movements without the freezing episodes which are prevalent with PD. Multiple treatment outcome measures are used to follow these patients and chart their changes in a multitude of areas as well, such as cognitive function, sleep patterns, physical function, sensation, fatigue, mental status, etc. Mr. Johnson has a good prognosis for PT using all of these interventions because he also has the support of his family and church. However, since there is currently no cure for PD, the disease will eventually take his life, so his family needs to be educated in what all the disease entails and be prepared for the days ahead after PT and medication can no longer slow the progressive killer.

References

Other references

Bhatt T, Yang F, Mak, M. K. Y., Hui-Chan, C., & Pai, Y. Effect of externally cued training on dynamic stability control during the sit-to-stand task in people with parkinson disease. Physical Therapy, 2013: 93(4), 492-503. doi:10.2522/ptj.20100423

Creath, R. A., Prettyman, M., Shulman, L., Hilliard, M., Martinez, K., MacKinnon, C. D., Rogers, M. W. Self-triggered assistive stimulus training improves step initiation in persons with Parkinson's disease. Journal of NeuroEngineering & Rehabilitation (JNER), 2013: 10(1), 1-10. doi:10.1186/1743-0003-10-11

Canning C G, Allen N E, Dean C M, Goh L, & Fung, V S C. (2012). Home-based treadmill training for individuals with Parkinson’s disease: A randomized controlled pilot trial. Clinical Rehabilitation, 26(9), 817-826. doi:10.1177/0269215511432652

Fox C, Ebersbach G, Ramig L, Sapir S. LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinson's Disease (20420080) [serial online]. January 2012;:1-12. Available from: Academic Search Complete, Ipswich, MA. Accessed July 16, 2013.

Ann M. H, James P. H, Kim B. S. Review: Stress, depression and Parkinson's disease. Experimental Neurology [serial online]. n.d.;233 (Special Issue: Stress and neurological disease):79-86. Available from: Science Direct, Ipswich, MA. Accessed July 16, 2013.

Walsh K, Bennett G. Parkinson’s disease and anxiety. 2001; 77:89-93. Available from http://pmj.bmj.com/content/77/904/89.full.pdf+html?sid=581203cf-ba91-4b7f-b7fc-e1e760409616. Accessed July 16, 2013.

Reuter I, Mehnert S, Sammer G, Oechsner M, Engelhardt M. Efficacy of Multimodal Cognitive Rehabilitation Including Psychomotor and Endurance Training in Parkinson’s Disease. Journal of Aging Research. 2012: 1-15.

General Conference of Seventh-day Adventists. Chemical Use, Abuse, and Dependency. 2013. Available at http://www.adventist.org/beliefs/statements/main-stat7.html. Accessed July 16, 2013

Jenkinson, Fitzpatrick, Peto, Greenhall, Hyman. The Parkinson’s Disease Questionnaire (PDQ-39): development and validation of Parkinson’s disease summary index score. Age and Ageing. 1997: 26; 353-357. Available from Oxford Journals [database online] at http://ageing.oxfordjournals.org/content/26/5/353.full.pdf. Accessed July 15, 2013.

Nasreddine. Montreal Cognitive Assessment. Available at: http://www.mocatest.org/pdf_files/instructions/MoCA-Instructions-English_2010.pdf. Accessed July 15, 2013.