Boxing Coach With Idiopathic Parkinson's Symptoms a Case Study

Boxing Coach With Idiopathic Parkinson's Symptoms a Case Study

Subjective Assessment:

A 60-year-old male patient presents with complaints of rapid fatigue, postural instability, and a lack of interest in all social events for the past two years. He was just diagnosed with idiopathic Parkinson’s disease at a local hospital in Oakville. He has been referred to physical therapy by his physician, after a serious of falls, in order to work on his balance. Also, he has been diagnosed with Diabetes Mellitus for the last ten years and has been receiving insulin therapy. Other than that, there is no other history of infections, illnesses or accidents in the last five years.  However, the patient has brought up concerns about depression and anxiety and has been referred to a psychiatrist for an assessment. He lives with his wife in a three-story building that requires him to walk three flights of stairs that includes thirty-six steps. The patient is a retired heavyweight boxer whose main passion still is boxing. He states that his central goal is to continue recreationally boxing at home or the gym. He is independent in all his activities of daily living except bathing and toileting, which he needs supervision from his spouse. The patient reports good strength in all limbs and has been able to walk independently. He enjoys taking thirty minute walks to the park, but he has noticed that he is starting to have a festering gait and is having trouble slowing down. Ultimately, he is concerned with his increase in falls lately. He  is afraid of falling and breaking his hip like his uncle Johnny, who died from the complications of a hip fracture.

Objective Assessment:

Posture: slight forward head posture, symmetrical, slight resting tremor in right forearm/ hand.

Strength: upper and lower extremities all within normal limits

ROM: upper and lower extremities within functional range of motion

Reflexes: biceps, triceps, brachioradialis, quadriceps and tendo achilles (all 1+ bilaterally)

Myotomes: normal bilateral

Dermatomes: normal bilateral

Tone: Mild non velocity dependent increase in muscle tone (MAS grade of 1+)

Dexterity: mild increase in tremor when completing UE tip to tip and pulp to pulp

Romberg: negative

Rapidly Alternating Movement Evaluation: negative

Point-to-Point Movement Evaluation: slight tremor when completing task bilaterally

Heel to shin: negative

Gait: Demonstrated an independent gait and the walking pattern showed mild features of festination, decreased step length, trunk flexion while walking, and shuffling gait.

Outcome measures

BERG Balance scale: 46/54

Multidirectional reach test: Forward 18.5 cm, Backward 10.0 cm, Left 13.5 cm, Right 14.0 cm

Clinical test for sensory integrity and balance (CTSIB)

1: Eye open + Firm surface 30/30 seconds

2: Eye closed + Firm surface  30/30 seconds

3: Visual conflict + Firm surface 30/30 seconds

4: Eye open + Compliant surface 26/ 30 seconds

5: Eye closed + Compliant surface 6/30 seconds

6: Visual conflict + Compliant surface 5/ 30 seconds

It should be noted that that this objective assessment was based off Winser et al., "A case study of balance rehabilitation in Parkinson's disease." (X)

Clinical Impression:

Analysis: Patient is a previously independent 60 year old male, who presents with decreased balance, mild increase tone, mild resting tremor, mild festinating gait, reports increased levels of fatigue with activity, and reports needing assistance with bathing and grocery shopping. Patients lives in a supportive home, however needs to climb 3 flights of stairs to get into his apartment. Patient is a good candidate for physiotherapy to help increase balance, decrease fatigue, increase tolerances to meaningful activities, and decrease the likelihood of future falls.

Problem list:

Decreased balance

Mild increased tone

Mild resting tremor

Mild festinating gait

Increased fatigue

Dependence with bathing and grocery shopping

Intervention:

Training the patient’s balance was the priority in order for him to return to activity. We prescribed strength training and foam mat balancing exercises to improve his balance (Toole et. al, 2000). We wanted to include strength training and balancing with focus mitts in order to replicate the skills needed to achieve a day-to-day coaching session. A second person was present when the patient was performing their balancing exercises for support. The following sequences of activities were performed for one hour for 10 weeks:

Strength/warm up

Exercise	Frequency	Intensity	Time	Type	Volume
Cycle ergometer	3 times a week	30% 1 Rep max (RM)	5 min	Warm up	1 set
Knee extension		3 lb ankle weights	2:1:4 s	Strength - eccentric	10 reps 3 set 2 min rest
Glute bridge		80% 1 RM	1:2:4 s	Strength - eccentric	10 reps 3 set 2 min rest
Ankle plantar flexion		Resistance band (RTB)	1:1:4 s	Strength - eccentric	10 reps 3 set 2 min rest
Walk	2 times a day 4 times a week	Comfortable walking speed	10 min (10% increase every week)	Endurance	2 sets

Foam Mat Balance (30 s holds, 3 sets, 1 min rest):

• Eyes open
  • Feet shoulder width apart
  • Feet together
  • Tandem
• Eyes closed
  • Feet shoulder width apart
  • Feet together
  • Tandem
• Eyes open, focus mitt with external perturbation
  • Feet shoulder width apart
  • Feet together
  • Tandem

Outcome:

Berg balance score:

53/54

Multidirectional reach test:

Forward 24.0 cm

Backward 13.0 cm

Left 17.5 cm

Right 18.0 cm

Clinical test for sensory integrity and balance (CTSIB)

4: Eye open + Compliant surface 30/ 30 seconds

5: Eye closed + Compliant surface 21/30 seconds

6: Visual conflict + Compliant surface 18/ 30 seconds

Patient is ready for outpatient physiotherapy to work on balance and progress strengthening program.

References:

Winser SJ, Kannan P. A case study of balance rehabilitation in Parkinson's disease. Global Journal of Health Science. 2011 Apr 1;3(1):90.

Shirely Ryan Ability Lab. Clinical Tests of Sensory Interaction on Balance [Internet]. Chicago: Shirley Ryan Ability Lab. [Updated 2013 November 13] Available  from: https://www.sralab.org/rehabilitation-measures/clinical-test-sensory-interaction-balance-vedge

Shirely Ryan Ability Lab. Multidirectional Reach Test Reach Four Directions test [Internet]. Chicago: Shirley Ryan Ability Lab. [Updated 2013 April 21] Available  from: https://www.sralab.org/rehabilitation-measures/multidirectional-reach-test-reach-four-directions-test