A physiotherapy approach to treatment for Lewy Body Dementia - case study

Abstract[edit | edit source]

Purpose: To determine the effects of a physiotherapy approach in managing the diagnosis of Lewy Body Dementia.

Case presentation: Mr. Ken Ten (Ken), a 58 year old male diagnosed with Parkinson’s disease at age 55 and recently diagnosed with Lewy Body Dementia presented at the clinic. Ken was referred to physiotherapy due to his decreased postural control and difficulty maintaining balance while walking and playing golf. Ken’s primary goals are to increase his participation in golf and leisure walking and to improve his overall balance.

Intervention: Ken’s physiotherapy intervention included education, strength training, stretching/ flexibility training, rigidity management, gait training and balance training. The LSVT-BIG intervention was also introduced.

Outcomes: After the 8 week intervention, Ken had improvements in his BBS, Mini-BESTest, TUG, Romberg Test, and MDS-UPDRS scores. Improvements were also noted in Ken’s gait. Ken was able to achieve goals involving walking endurance, balance, and participation in chores/golfing.


ADL = activities of daily living

AP = anterior-posterior

BBS = Berg balance scale

BOS = base of support

EC = eyes closed

EO = eyes open

HEP = home exercise plan

IADLs = instrumental activities of daily living

ICF = International Classification of Functioning, Disability and Health

LBD = Lewy body dementia

LE = lower extremity

MDS-UPRDS = Movement Disorder Society-Unified Parkinson's Disease Rating Scale

Mini-BESTest = Mini Balance Evaluation Systems Test

ML = mediolateral

NT = not tested

PD = Parkinson’s disease

PDD = Parkinson’s disease with dementia

REM = rapid eye movement

ROM = range of motion

TUG = Timed up and go

UE = upper extremity

Introduction[edit | edit source]

Lewy body dementia (LBD) is a progressive disease that involves dementia and parkinsonism. There are two types of LBD; Dementia with Lewy Bodies and Parkinson’s disease with dementia (PDD), where both are categorized based on the onset of cognitive deficits after a Parkinson’s diagnosis. Commonly misdiagnosed, PDD specifically involves cognitive deficits which appear more than one year after the onset of parkinsonism. Unfortunately, mortality of LBD is typical 5 to 7 years from onset to death[1]. There are extensive clinical presentations and patient challenges of LBD, including fluctuating cognitive deficits, impairments with movement, sleep, behaviour, mood, and memory[1]. The purpose of the following fictional case study, which was created for educational purposes, is to determine the effects of a physiotherapy approach in managing the diagnosis of PDD. With the given physiotherapy approach, effective techniques and interventions will focus on managing the impairments of function and activities stemmed from the disease.

Client characteristics[edit | edit source]

Mr. Ken Ten is a 58 year old male, who was diagnosed with Parkinson’s disease (PD) when he was 55 years old. Approximately 6 months ago, he received a diagnosis of LBD (stage 1 out of 5)[2]. Due to the timeline of the onset of the cognitive deficits, Ken is considered to have PDD. Ken has experienced problems with maintaining balance and postural control (risk of falls), freezing during gait, slightly stooped posture, tremors in both hands at rest and generalized slowness of movements (bradykinesia). Some days, he has also had trouble with multitasking, paying attention to his daily tasks, and remembering to take his medication. He experiences excessive daytime sleepiness, and sometimes reports seeing things that aren’t there (i.e. he occasionally tells his wife that he sees a bear in the backyard when there is no bear). At the time of Ken’s PDD diagnosis, he was also diagnosed with REM sleep disorder and restless leg disorder. Approximately 7 years ago, Ken was diagnosed with type-2 diabetes, and within the last year, he was diagnosed with depression.

Ken was referred to physiotherapy due to his decreased postural control and has difficulty maintaining his balance while walking and playing golf. Ken has been playing golf for the past 10 years, and is really passionate about it. Unfortunately, he has noticed that his ability to play golf has decreased. He regularly experiences issues with regards to his balance; he is finding it more difficult to maintain balance during the backswing stance and while initiating the downswing. He is also becoming more easily fatigued while playing golf and requires a 10 minute break in between holes if he walks between them. He hopes that physiotherapy can help him resolve some of his golf related issues, and improve his overall balance.

Examination findings[edit | edit source]

Subjective[edit | edit source]

Patient profile: Ken Ten is a 58-year-old male is an investment banker who has been working from home since March 2020, the start of the COVID-19 pandemic.

History of present illness: Ken was diagnosed with PD when he was 55 years old, and 6 months ago he was diagnosed with LBD after presenting with difficulty paying attention, multi-tasking, visual hallucinations, increased difficulty sleeping, difficulty with remembering to take medication.

Past medical history: When Ken was diagnosed with LBD, he also received a diagnosis of REM sleep disorder and restless leg disorder. Ken was diagnosed with type-2 diabetes approximately seven years ago. Within the last year, Ken was diagnosed with depression.


  • Levodopa/carbidopa 250 mg 3 times day with meals
  • Clonazepam 0.25–0.5 mg at night
  • Glumetza 500 mg once a day with a meal
  • Escitalopram 10 mg once daily

Health habits: No history of smoking, occasional alcohol consumption (1-2 drinks/ week), no history of recreational drug use.

Family history: No family history of LBD or PD. He had an uncle with type-2 diabetes on his dad’s side.

Social history: Ken lives with his wife, has 2 sons (1 lives in town, 1 lives in another province), has many golf buddies that live in his neighbourhood (has not been able to see them due to COVID-19).

Previous & Current Functional Status: Before the PD diagnosis, Ken was independent with activities of daily living (ADLs), but he is currently experiencing difficulties with dressing and eating (mainly due to tremors). Previously independent in all instrumental activities of daily living (IADLs), Ken is currently not doing things like chores around the house and he has had some trouble remembering to take his medication. Previously, Ken would go for an hour-long walk daily, but now he only walks 20 minutes daily and takes a short break half way through. Ken previously golfed biweekly but more recently he has found himself needing a 10 minute break after walking between holes (could not go more than one hole without needing a break/needing the golf cart instead of walking to avoid having to take a break).

Precautions/contraindications: Attention challenges may affect ability to participate in therapy (keep things simple), memory challenges (blocked practice, simple exercises, repeat lots), occasional hallucinations (be aware of), balance challenges may limit the patient’s ability to participate in therapy alone/at home (guard closely).

Objective[edit | edit source]

Observation[edit | edit source]

  • Ken stated that he was in the typical ON-stage of his Parkinson's medication.
  • General: slowness of movements walking into room and sitting in chair, masked facial expressions, resting tremor in hands bilaterally, hands remained remained still on lap during subjective interview (decreased spontaneous movements).
  • Posture: stooped in standing, forward head posture and rounded shoulders in sitting and standing.

Gait analysis[edit | edit source]

During Ken’s initial assessment, a video was taken of his gait. This video was used for gait analysis.

  • Gait speed: decreased relative to his age (based on TUG score)[6]
  • Stance/step width: narrowed/decreased.
  • Step length: decreased bilaterally, shuffling gait.
  • Swing phase: decreased bilateral dorsiflexion, decreased foot clearance.
  • Turning: festinating gait, increased number of steps taken to complete 180° turn to left and right.
  • Arm swing: decreased bilaterally, right side greater decrease.

Postural Instability/Balance[edit | edit source]

  • Quiet standing: mild anterior-posterior sway, minimal medio-lateral sway.
  • Romberg Test
Table 1: Ken’s Romberg Test scores taken upon initial assessment. Averaged over 3 trials, recorded in seconds. Not tested (NT) due to safety concerns.
Eyes Open (EO) Eyes Closed (EC)
Feet together 23 7
Tandem Stance 18 5
Single Leg Stance Left 12 NT
Single Leg Stance Right 10 NT
  • Pull Test: Score = 1 (the patient took 3 steps but could recover independently).

Range of Motion (ROM)[edit | edit source]

  • UE scan: within normal limits.
  • LE scan: within normal limits.
  • ROM mostly affected by the patient’s rigidity (e.g., with an activation maneuver (UE or LE) the contralateral limb exhibits rigidity that limits ROM), which is further discussed below.

Hand Grip Strength[edit | edit source]

Table 2: Ken’s Hand Grip Strength measured with a hand dynamometer taken upon initial assessment. Averaged over 3 trials, measured in kilograms (normative data for males aged 50-59 years)[7].
Left Right
Average 32.5 (43) 35.5 (45)

Rigidity[edit | edit source]

  • Assessed by passive range of motion with addition of an activation maneuver if indicated.
  • Wrist: Rigidity only present on the right side with the addition of an activation maneuver (tapping left hand on left thigh), cogwheel rigidity also observed.
  • Elbow: Rigidity only present on the right side with the addition of an activation maneuver (tapping left hand on left thigh), cogwheel rigidity also observed.
  • Ankle: Rigidity only present on the right side with addition of an activation maneuver (tapping left heel on ground).
  • Knee: Rigidity only present on the right side with addition of an activation maneuver (tapping left heel on ground).

Tremor[edit | edit source]

  • Resting tremor: observed in hands bilaterally, 1 cm amplitude.
  • Postural tremor: observed in hands bilaterally after 12 seconds.
    • Test Position: sustained bilateral shoulder flexion at 90 degrees, elbows extended, pronation.
  • Kinetic tremor: observed in left hand at 8th rep and right hand at 9th rep.
    • Test Position: repeated (x10) finger to nose test unilaterally with therapist.

Bradykinesia tests[edit | edit source]

  • See Results of finger tapping, hand movements, pronation-supination movements, toe tapping, and leg agility in Table 3 below.
Table 3: Results of bradykinesia tests from the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS).
Finger Tapping - Right Hand 2
Finger Tapping - Left hand 1
Hand Movements - Right Hand 2
Hand Movements - Left Hand 1
Pronation-Supination - Right Hand 2
Pronation-Supination - Left Hand 1
Toe Tapping - Right Foot 2
Toe Tapping - Left Foot 1
Leg Agility - Right Leg 2
Leg Agility - Left Leg 1
    • Part 1: Non-Motor Aspects of Experiences of Daily Living = 28 (11.5)
    • Part 2: Motor Aspects of Experiences of Daily Living = 26 (16)
    • Part 3: Motor Examination = 31 (36.8)
    • Part 4: Motor Complications = 5 (4.0)
    • Overall = 92 (68.4)
    • *normative data on the score is given in bold beside Ken’s score[8]

Clinical impression[edit | edit source]

Physiotherapy Diagnosis[edit | edit source]

Ken is a 58-year-old man recently diagnosed with LBD where he had been previously diagnosed with PD three years prior. Based on the subjective interview and objective exam findings, Ken experiences rigidity and tremors, impaired motor and postural control, and decreased independence affecting his function, balance, gait, and activities of daily living. Specifically, Ken has difficulties with eating, dressing himself, and playing golf. Although Ken demonstrates difficulties and deficits, he is independent with gait and transfers, and he does not use a gait aid, nor requires assistance for any. Ken is a suitable candidate for physiotherapy due to his motivated nature, and will benefit from 8 weeks of physiotherapy interventions aimed at improving strength, balance, gait and functional mobility. Due to the progressive nature of LBD, Ken will be at further increased risk for falls in the future.

Problem List[edit | edit source]

A problem list for Ken was proposed using the International Classification of Functioning, Disability and Health (ICF) model.

Body Structure/Function[edit | edit source]

  • Decreased balance, even in the ON-stage of medication.
    • 48/56 on the BBS.
    • 20/28 on Mini-BESTest.
  • Abnormal gait pattern.
    • Decreased gait speed (relative to his age).
    • Decreased stance width.
    • Decreased bilateral dorsiflexion during swing phase leading to a decrease in foot clearance.
    • Decreased step length leading to shuffling.
    • Festinating gait observed before turning 180°.
    • Several steps with turning 180°.
    • Decreased arm swing (right UE worse than left) during swing and stance phase.
  • Increased rigidity in right extremities (rigidity only with activation maneuver).
  • Fluctuating difficulty with paying attention, multitasking and memory on some days.

Activity Limitations[edit | edit source]

  • Decreased independence due to tremors and postural instability.
  • Decreased function with ADLs (dressing, eating), IADLs

Participation Restrictions[edit | edit source]

  • Decreased abilities while playing golf - maintaining his balance during the backswing stance, initiating the downswing and putting technique.
  • Decreased endurance – Ken’s daily walks have decreased from one hour to 20 minutes, and he requires a break halfway through, requires breaks between holes and sometimes needs the golf cart to take him to the next hole.
  • Depression and anxiety have limited Ken from participating in the things he likes to do and decreased his motivation to be more active.

Intervention[edit | edit source]

Short Term Goals[edit | edit source]

Short term goals were made with Ken and categorized under education, balance, or activity/participation goals.

Education[edit | edit source]

  • Ken will accurately explain and demonstrate the strengthening and stretching exercises in his home exercise plan (HEP) by the end of the 2nd treatment session.
  • Ken will demonstrate accurate knowledge about the prevention of loss of balance and recovery from falls by the end of the 4th treatment session.
  • Ken will demonstrate knowledge on the importance of posture during gait to reduce the risk of falls by the end of the 2nd treatment session.

Balance[edit | edit source]

  • Within 3 weeks, Ken will improve his Romberg Test feet together EO to 30 seconds.
  • Within 3 weeks, Ken will improve his Romberg Test tandem stance to 25 seconds.
  • Within 3 weeks, Ken will improve his Romberg Test single leg (L) and (R) EO scores to 18 seconds and 15 seconds, respectively.

Activity/Participation[edit | edit source]

  • Within 3 weeks, Ken will walk 15 consecutive minutes before continuing the last 5 minutes of his walk (i.e. total time 20 minutes).
  • Within 3 weeks, Ken will play 2 consecutive holes as opposed to one before stopping for rest.
  • Within 3 weeks, Ken will be able to take on 10% more chores around the house.

Long Term Goals[edit | edit source]

Long term goals were made with Ken and categorized under different areas. With the achievement of the above short term goals, categories of gait and strength were added to the long term goals.

Balance[edit | edit source]

  • Within 6 weeks, Ken will have increased balance (AP and ML balance) during his backswing during golf.
  • During perturbation training using an overhead harness in the clinic, Ken will be able to demonstrate how to recover from loss of balance (i.e. how to properly fall to avoid serious injuries) within 6 weeks.

Gait[edit | edit source]

  • Within 6 weeks, Ken will use 4 steps to turn around 180° as opposed to 7 steps.
  • Within 8 weeks, Ken will exhibit decreased festination prior to turning 180° and when terminating gait (improved posture during gait).
  • Within 6 weeks, Ken’s gait speed will increase and he will be able to achieve 9 seconds to complete the TUG.
  • Within 8 weeks, Ken will demonstrate a decreased shuffling due to increased step length during gait.

Activity/Participation[edit | edit source]

  • With an improvement in endurance within 6 weeks, Ken will be able to play 3 consecutive holes, as opposed to 1 before stopping for rest.
  • With an improvement in endurance within 6 weeks, Ken will need less than 10 minutes of rest between holes while playing golf.
  • Within 6 weeks, Ken will be able to walk 20 minutes without needing to take a break due to fatigue.
  • Within 7 weeks, Ken will be able to take on 25% more chores around the house.

Strength[edit | edit source]

  • Within 5 weeks, Ken will improve dorsiflexion strength bilaterally, allowing sufficient foot clearance during gait.
  • Within 7 weeks, Ken will improve hand grip strength on the left to 43 kg and the right to 45 kg.

Management Plan[edit | edit source]

The physiotherapy management plan is going to consist of a variety of components, including education, strength training, stretching/ flexibility training, rigidity management, gait training and balance training.

Education[edit | edit source]

An important part of Ken’s management plan is education. He will be educated on the importance of flexibility/ stretching to improve posture and counteract rigidity, strength training to improve posture, and the importance of correct posture during gait to reduce the risk and/or prevent falls. Because he is experiencing difficulties with balance, he will be educated on the importance of falls prevention and recovery training. Education will be provided on what a typical/regular gait cycle looks like so that while undergoing gait training, he will have a general idea of what we want to work towards. Lastly, education will be provided on the progressive nature of LBD. It is important for Ken to understand that he can delay severe symptoms as the disease progresses, but that he will not be able to function the same way he was prior to his diagnosis.

Strength Training[edit | edit source]

Strength training will be included in the management plan to address weakness of postural muscles, muscles affecting gait, core muscles and to improve hand grip strength. Table 4 below highlights potential exercises that could be introduced to Ken. Based on how Ken responds to the exercises, we would progress the exercises to make them more difficult.

Table 4: Exercises used for Ken’s strength training, duration of 8 weeks. Strength training was performed at least 3 days per week.
Postural muscles - back and neck extensors, hip extensors, knee extensors Chin tucks (cervical retraction) - neck extensors

Bird dog


10 reps x 2 sets, 3 minutes of rest in between sets
Weak LE muscles involved with gait and UE muscles - ankle dorsiflexors (tibialis anterior), ankle plantarflexors (gastrocnemius, soleus), hip flexors, biceps brachii, deltoids Calf raises

Ankle dorsiflexion with resistance band

Biceps curls

Lateral raises, front raises with weight

10 reps x 2 sets, 3 minutes of rest in between sets
Core strengthening Palloff press (anti-rotation exercise)

Lateral ball toss with therapist or wife (Note: to progress this exercise, the weight of the ball with be increased)

10 reps x 2 sets, 3 minutes of rest in between sets
Hand grip strengthening Stress ball squeeze 10 reps x 5 second hold, 2 sets. Rest as needed between sets.

Cue will be provided to open hand fully (extend fingers fully) between each rep

Stretching/Flexibility Training[edit | edit source]

This is one example of a posture board that Ken may use.

Ken exhibits forward head posture and an anteriorly translated humerus. To address this postural issue, a posture board will be used to stretch his pectoralis muscles. He will begin with a stretch of 1 minute/day on day 1, and then increase 30 seconds each day, to a maximum of 20 minutes/ day.

Rigidity Management[edit | edit source]

To counteract rigidity, focus will be placed on stretching and flexibility. Static stretches of the wrist extensors, elbow flexors, knee flexors and ankle plantarflexors will be implemented. The static stretches will be held for 30 seconds and will be performed 4 times per day, 7 days per week.

Gait Training[edit | edit source]

The main focus of gait training for Ken will involve using visual and auditory cues to help generate a more regular gait pattern and help reduce the duration of an episode of freezing. A laser cane will be one of the methods employed to provide Ken with a visual cue while walking. Additionally, environmental cues, such as following a line on the floor, following the lines on hardwood flooring etc. will also be used. The therapist will also provide verbal coaching (e.g. “take a big step”) for Ken as needed. Auditory cues, such as walking with a metronome or walking to the beat of a song will also be used to improve Ken’s gait[9].

Balance Training[edit | edit source]

Balance training and exercise in the form of strength training have demonstrated improvements in balance and gait performance, as well as decreasing the number of falls in patients with Parkinson’s disease[10]. Ken has reported difficulty with balance in walking and while playing golf, making balance training an essential part of his management plan. The different areas of focus for balance training, along with example exercises/ tasks that will be implemented for Ken are described below. Table 5 highlights potential exercises that could be introduced to Ken. Based on how Ken responds to the exercises, we would progress the exercises to make them more difficult.

Table 5: Areas of focus related to balance training and the exercises/tasks implemented for each.
Area of focus Exercises/Tasks
Improve specific components of the Berg balance scale and mini-BESTest

(each of the tasks will be performed 3-4 times/ week (2 days/ week at the clinic, 1-2 days/ week at home)

  • Heel to toe (tandem) walking along a 5m line – 5 reps x 2 sets, 1 minute rest between attempts
  • Place alternate foot on step or stool – 8 steps x 2 sets, as fast as possible without losing balance, 1-2 minute rest between sets.
  • Single leg stance (L and R leg) – 2 reps x 15 seconds, 30 sec – 1 minute rest in between sets
Functional balance training – focus on golf related tasks
  • Weight transferring during swing (to improve transitioning from backswing to downswing) - 2 sets of 10 reps at a tempo 3:0:3:0 progressing to full regular swing
  • Feet planted with arm movements, progressing to arm movements with trunk rotations - 2 sets of 10 reps with 20 second holds
  • Using different surfaces – start with firm, flat surfaces and move to uneven surface training
Internal perturbation training (mainly performed at home)

(each exercise will be performed daily; 2 sets of 20 different reaching angles)

Multidirectional reaching tasks

Progressions for reaching task:

  • Start with closer distances and then progress to reaching further away
  • Vary the base of support (BOS) – begin with reaching with a wide, stable BOS to reaching in narrower BOS (tandem stance)
  • Vary the surface – begin with reaching tasks on ground and progress towards unstable surfaces (foam pad)
External perturbation training at the clinic

(each exercise will be performed daily; 2 sets of 20 different perturbations)

Perform nudges on the patient

Progression for nudging task:

  • Begin with expected nudges and progress to unexpected nudges
  • Start will small perturbations and progress to larger perturbations

LSVT-BIG[edit | edit source]

To address Ken’s bradykinesia, the LSVT-BIG intervention will be used. This intervention has been shown to be more effective than regular physiotherapy for improving the motor components of the UPDRS[11]. This intervention will be implemented by a therapist in the clinic, who has formal education regarding the LSVT-BIG intervention. An example of some of the LSVT-BIG exercises can be found in the video below:

Role of non-physical therapy members of healthcare team[edit | edit source]

Lewy body dementia is a complex disease that requires a multi-disciplinary approach[12]. While physical therapists can help keep patients active and participating in their activities of daily living, there are many other factors that contribute to treatment for these individuals including pharmaceutical interventions, advance care planning, and identification of triggers to name a few. Psychiatrists are large contributors on the multidisciplinary team helping plan both pharmacological and nonpharmacological interventions[13]. When considering neuropsychiatric symptoms, the psychiatrists may assist with pharmaceutical treatments. Several examples of pharmaceutical interventions include as prescribing cholinesterase inhibitors to help with hallucinations or delusions, while avoiding prescription of antipsychotics due to the complications they can cause in this population, including worsening of parkinsonism and significant changes in conscious state[12]. There are also nonpharmacologic interventions that may be included like psychoeducation of the caregiver and patient, social stimulation, environmental modification, and identifications of potentially reversible triggers. Psychoeducation of the caregiver and patient would involve explaining the diagnosis while emphasizing that treatment will aim to control symptoms and involve establishing priorities to guide treatment. These education sessions may also include discussions on the benefits of maintaining a safe and familiar environment with cues to orient the patient to where they are and identifying any potentially reversible trigger like hunger or pain that can easily be avoided.

One crucial member to the multidisciplinary approach, who is sometimes overlooked or forgotten, is the social worker. While the individual who has LBD is likely well supported by their health team, the social worker can help support the patient’s entire family, particularly those family members who are taking on a caregiver role. Caring for family members can be stressful; it can lead to burden, stress, and feelings of resentment for the spouse who finds themself to be in that supporting role[14]. It has been found that caregivers who receive assistance in the form of help with preparing meals and daily chores as well as those who had higher levels of emotional support through being given solutions and advice experienced higher levels of depressive symptoms[15]. It has been suggested that those depressive symptoms come from a feeling of guilt that they cannot manage to care for their loved one leading to a sense of helplessness and depression. Additionally, familial caregivers with high levels of self-efficacy and resiliency, social supports to help them buffer guilt and affectionate support experience fewer depressive symptoms. Social workers can help by providing psychosocial education groups where caregivers have the opportunity to learn from others, get tools to cope with challenging situations from people who understand their experiences, and improve caregivers capacity to manage tasks. It is important that caregivers are educated about what to expect as their loved one’s disease progresses. Social workers may organize both online and in-person support groups where caregivers can share their experiences, tips for stress management, and other resources. Focus groups lead by social workers can help caregivers feel a sense of belonging and increase their self efficacy through learning about ways to minimize negative thoughts about their role as a caregiver, develop effective coping strategies and increase their knowledge about dementia related tasks and symptoms.

Here the role of psychiatrists and social workers were highlighted including a brief overview as to some of the interventions they may be involved in when caring for individuals with LBD. These are by no means the only roles that these health care professionals play in caring for these patients and they are part of a large multidisciplinary team. Psychiatrists were included here to show the depth of their involvement in both pharmaceutical and non pharmaceutical treatments while social workers were included to highlight the importance of considering everyone who is affected by a LBD diagnosis and to remind us that while treating the patient is important, that there are many other individuals closely involved who also need the support of the healthcare team.

Now that the role of psychiatrists and social workers have been identified, their contribution to Ken’s care can be examined. A psychiatrist would be working closely with Ken and his health team to find the best medications and doses for his symptoms. Psychoeducation with Ken and his family would also be a large part of the psychiatrist’s role. At Ken’s stage of the disease, education would include what to expect as the disease progresses, identifying and learning how to avoid triggers, and environmental modification to ensure that Ken can ambulate independently around his home safely. Social worker involvement for Ken would supplement the psychoeducation received from the psychiatrist but would also involve his family and support system. While a social worker would work to help Ken, they would play a large role in educating and supporting his wife in her new caregiver role. Ken’s wife would have the opportunity to attend focus and psychoeducation groups to help give them the tools she needs to support Ken including increasing her self-efficacy and giving her a sense of belonging. The social worker would continue to provide additional support for Ken’s family as Ken’s disease progresses to help them process all of their emotions.

Outcomes[edit | edit source]

Ken attended physiotherapy at the clinic twice a week and performed at-home interventions nearly every day for 8 weeks in total. After following the treatment protocol detailed above, outcome measures were taken once more to compare Ken’s status post-intervention to his pre-intervention status.

  • Berg Balance Scale: Ken’s score improved from 48/56 to 51/56[16]
  • Mini-BESTest: Ken’s score improved from 20/28 to 23/28
  • TUG: Ken’s score improved from 10.5 seconds to 8.0 seconds[6]
  • MDS-UPDRS Scoring post-intervention (vs. normative data for Parkinson’s Disease)[17][8]
    • Part 1: Non-Motor Aspects of Experiences of Daily Living = 22 (11.5)
    • Part 2: Motor Aspects of Experiences of Daily Living = 20 (16)
    • Part 3: Motor Examination = 31 (36.8)
    • Part 4: Motor Complications = 4 (4.0)
    • Overall = 77 (68.4)
  • Romberg Test
Table 6: Ken’s Romberg Test scores taken after 8 weeks of rehabilitation. Averaged over 3 trials, recorded in seconds. Not tested (NT) due to safety concerns.
Eyes Open (EO) Eyes Closed (EC)
Feet Together 28 9
Tandem Stance 24 7
Single Leg Stance Left 15 NT
Single Leg Stance Right 13 NT
  • Pull Test
    • Outcome: 1 (Ken took 3 steps but could recover independently)
  • Hand Grip Strength
Table 7: Ken’s Hand Grip Strength measured with a hand dynamometer taken after 8 weeks of rehabilitation. Averaged over 3 trials, measured in kilograms (vs. normative data for 50-59 years of age, bolded)[7].
Left Right
Average 38 (43) 43 (45)

Gait analysis post-intervention[edit | edit source]

When Ken was initially assessed, a video of his gait was taken. This video was used for gait analysis. Another video was taken after 8 weeks of intervention and Ken’s gait was analyzed. Below are the details of Ken’s gait analysis post-intervention in comparison to the initial gait assessment.

  • Gait speed: increased, 2.5 second improvement on TUG
  • Stance/step width: step width increased
  • Step length: increased bilaterally, less shuffling pattern observed
  • Swing phase: increased bilateral dorsiflexion, improved foot clearance
  • Turning: upright posture gait, reduced number of steps to 4 to complete 180° turn to the left and right
  • Arm swing: increased arm swing on his right side, still asymmetrical compared to left

Analysis of intervention[edit | edit source]

With Ken, we looked back on Ken’s problem list, short term goals, and long term goals created during the initial assessment. One area of focus was Ken’s balance. Ken’s post-intervention scores on the BBS, Mini-BESTest, and Romberg Test indicate that his balance has improved since the initial assessment. Ken also feels that his balance has improved during his backswing, downswing and putting during golf. Another area of focus was strength training. Ken’s hand grip and dorsiflexion strength improved as measured with the hand dynamometer and observed foot clearance during gait, respectively. There was also a key focus on improving Ken's gait. As described in the post-intervention gait analysis section, Ken’s gait has improved in terms of gait speed, step width, and step length. He is also demonstrating improved foot clearance, less shuffling, increased arm swing (specifically on the right) and improved posture during gait. Ken stated that he was able to achieve his goal of being able to take a walk for 20 minutes before needing a break. On good days, he says he can walk 30 minutes before taking a rest. Finally, Ken had a goal of taking on 25% more chores around the house after his 8 weeks of intervention, and he stated that he has taken on more activities like sweeping, mopping, dusting, and taking out the garbage among other things he was not previously doing. Based on these findings, we have concluded that Ken has improved after receiving physiotherapy intervention.

Discharge planning[edit | edit source]

At this time, Ken’s 8 week treatment intervention has concluded. Both Ken and the physiotherapy team are pleased with his improvements following the intervention. Ken understands that LBD is a progressive disease and his condition will decline, so he has asked that his file remain open so he can follow up if he is having any difficulty or has noticed any decline. The physiotherapy team is happy to keep Ken’s file open. The discharge planning will include ensuring that Ken understands his condition will progress but he can work to slow the progression of the clinical symptoms of the disease by continuing with his HEP of strengthening and stretching. Ken must continue to focus on his gait techniques and practice strategies to prevent falls and strategies to recover after a fall. Ken might be able to delay the severity of his symptoms if he remains diligent in keeping up with his exercise program as his disease progresses.

Ken should continue to follow up with his psychiatrist to monitor his cognitive status and monitor the condition and adjust any medications as necessary, and also continue to follow up with his family physician for medications involved with his parkinsonism. Ken and his family should continue working with his social worker as well; as Ken’s condition progresses there will likely be more difficulties that the social worker can help them manage. As mentioned above, Ken is welcome back to the clinic if he ever feels the need to implement further physiotherapy intervention.

Discussion[edit | edit source]

As previously described, Lewy body dementia is a detrimental disease which demonstrates many clinical presentations. Ken's impairments included rigidity, tremors, postural instability, decrease in balance and abnormal gait patterns. All of which limited his independence and ability to function during his activities of daily living, including eating and dressing. In addition, Ken reports he experiences cognitive deficits such as depression, anxiety and lack of motivation. Being an avid skilled golfer, Ken unfortunately experiences issues affecting his golfing, such as a decrease in efficient swing technique and decrease in overall fitness endurance when walking from hole to hole. Ken and all appropriate health care professionals derived a detailed problem list, and corresponding short- and long-term goals once a detailed assessment was completed. Specific outcome measures relevant to Ken’s condition were the BBS, Mini-BESTest, TUG, as well as the MDS-UPDRS. Physiotherapy interventions were focused on education (fall prevention, importance of physical activity); strength, stretching/flexibility training; endurance training; gait retraining; and balance training (internal and external perturbations).

Ken presented key deficits which can be observed with a typical patient with LBD. Based on the case presented, ramifications of managing patients diagnosed with LBD are focused on clinical interventions. Education is key to any physiotherapy intervention and should be prioritized regardless of the patient’s condition, injury or disease. Education in Ken’s case revolved around the importance of exercises in improving posture, gait, balance, as well as fall prevention and fall recovery. Education also focused on progressive nature of LBD. Strength training addressed weakness in postural muscles, core muscles and general musculature involved in gait. Strengthening training key muscles listed will translate to improved gait patterns and generalized improvement with activities of daily living. Flexibility training was aimed at addressing the poor posture, specifically forward head posture. Rigidity must be addressed via flexibility training targeting the wrist extensions, elbow flexors, knee flexors and ankle plantarflexors. Balance training is key to a physiotherapy management of LBD, as it will translate to improve gait performance and decreased number of falls[10]. Balance training included improving specific components of the BBS, sport-specific and functional balance training, and internal and external perturbation training. Finally, addressing the hallmark symptom of PD, bradykinesia was managed with the LSVT-BIG intervention, which was shown to improve motor components of the MDS-UPDRS[11].

Self-study questions[edit | edit source]

1) Lewy Body Dementia (LBD) is a progressive disease that is characterized by which of the following?

  1. Sleep disturbances
  2. Cognitive difficulties
  3. Bradykinesia
  4. Muscles rigidity
  5. 2, 3, and 4
  6. All of the above

2) Which of the following statements is false with regard to Lewy Body Dementia (LBD) ?

  1. On average, mortality is within 5 to 7 years from onset to death.
  2. Stretching may help to reduce the muscles rigidity in LBD
  3. Focusing on external perturbation training is more important than internal perturbation training
  4. Pharmacological treatment may be helpful in symptom management
  5. There are two presentations of LBD, and the difference between them depends on the onset of cognitive deficits
  6. There are multiple health care professionals that can be involved in the care of a patient with LBD

3) Physiotherapy interventions for LBD should focus on all of the following except:

  1. Postural education
  2. Balance training
  3. Gait retraining
  4. Cognitive rehabilitation
  5. 1, 2, and 3
  6. All are correct answers


1) 6

2) 3

3) 4

Resources[edit | edit source]

Alzheimer's Association - Lewy body dementia (American source).

Alzheimer's Society - dementia with Lewy bodies (UK source).

Alzheimer's Society of Calgary - Lewy body dementia (Canadian source).

Alzheimer's Society of Canada - Lewy body dementia (Canadian source).

Dementia Australia - Lewy body disease (Australian source).

Dementia UK - Lewy body disease (UK source).

Lewy body dementia association (American source).

Lewy body dementia Canada (Canadian source).

Merck Manuals - dementia with Lewy bodies and Parkinson disease dementia (American source).

National Institute of Aging - What is Lewy body dementia? (American source).

References[edit | edit source]

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