Parkinson's Case Study

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Exercise and LSVT-BIG in moderate stage Parkinson's Disease: a case study

Abstract

The following case study illustrates a 54-year old man with middle stage Parkinson’s Disease, marked by difficulties with gait, increased stiffness and reduced range of motion (ROM), cogwheel rigidity, resting tremor, and some issues with coordination. Patient-centered goals were developed, surrounding increasing Timed-Up and Go (TUG) score, improving ROM and coordination, being able to continue participating in dancing with his wife, as well as navigating throughout his home with less difficulties. A 4-week “LSVT Big”-style training program was proposed, in order to work towards these goals, that included both supervised training, a home exercise program, as well as an educational component. Following this training program, the patient displays improvements in balance, gait, as well as reduced parkinsonism. His confidence has improved, and he is much less worried in general, than during his initial assessment.

Introduction

Parkinson's Disease is a neurological progressive disorder associated with the degeneration and eventual loss of dopaminergic cells in the substantia nigra pars compacta. Based on statistics from 2012-2013, approximately 84,000 Canadians 40 years and older were diagnosed with parkinsonism and 10,000 Canadians were newly diagnosed with Parkinson's Disease, with a higher prevalence in males compared to females [1]. Those with this condition typically present with bradykinesia, tremors and rigidty and progression of the disease can be associated with loss of independence in basic Activities of Daily Living and Instrumental Activities of Daily Living [2].  Currently, there is no cure for the disease but there are multiple treatments to slow the progression of the disease. Treatment aims to control symptoms, optimize activity and participation and improve quality of life in all stages of the disease [2].

Previous studies show that exercise programs targeting gait, balance, transfers or physical capacity can reduce motor symptoms [2]. Movement programs specifically addressing hypokinesia and bradykinesia such as the Lee Silverman Voice Treatment or LSVT-Big, requires the patient to think big when initiating and carrying out movements to increase the speed and amplitude of movement [3]. Studies found that 1-hour sessions, 4x a week for 4 weeks showed promising results when compared to shortened intervention or regular physiotherapy, improving the Unified Parkinson's Disease Rating Scale specifically the motor components. These studies also showed trends towards better outcomes in gait speed and TUG scores [4].

Client Characteristics

Ted is a 54-year old man with a 2-year diagnosis of middle stage Parkinson’s Disease. He has been experiencing an increase in the severity of symptoms regarding the slowness of movement and tremors. He has been referred to outpatient physiotherapy for management and a home exercise program.

The patient is a retired carpenter who was previously very active with a history of hypertension and high cholesterol. Ted enjoyed keeping himself busy by doing small renovations around the house, going to dance classes with his wife and visiting their grandchildren. He and his wife live in a two-story home outside of Kingston. They have three children; one daughter who travels frequently, a son who lives in the city with his wife and two young children and another son who lives with his family in British Columbia. Ted retired early to support his wife who was diagnosed a few years ago with early-onset Alzheimers, which they were managing well prior to Ted’s worsening symptoms.

Examination Findings

History of Present Illness

The onset of his Parkinson’s diagnosis started with Ted experiencing difficulties with regular tasks around the house because he was experiencing ‘shaking’ and noticed a lot of his movements were much slower and difficult to ‘get going’. His son suggested he see his doctor after witnessing him have difficulty entering the front door of his home, ‘he was frozen and needed guidance to step in’. Prior to these symptoms, Ted recalls losing his sense of smell intermittently and noticed his handwriting becoming smaller but dismissed these as part of “getting old”.

Current Status

The patient spoke about how he has become heavily reliant on the medications he was given by his physician of Levodopa and Trihexyphenidyl. He has indicated that they are effective at "taking his shaking and slow movement away" but that the effects tend to wear off quickly. Ted reported having difficulty initiating movements, stiffness and slowness in general, explaining that he often "freezes" when having to walk through narrow spaces and has hesitation with turning. His shaky movements in his dominant hand (right) prevent him from working on small projects in his shed and completing his regular tasks around the house, stating that sometimes he will "miss" his television remote. Ted raised concerns over having trouble adapting to his condition as he is the primary caregiver for his wife and is worried about losing his independence. He goes on to share that he has always been the provider for the family and fears for what his condition will do for him and his wife moving forward. Recently, Ted had to move his bedroom to the main floor as his children were concerned with him helping their mother up and down the 10 steps of stairs in their home.

His goals include improving walking through doorways and turning, continue doing projects in his shed and return to dance classes with his wife. He is independent with his activities of daily living and ambulates using a quad cane. He did not have any problems with transfers. He presented with mild kyphosis and stooped posture and spoke with mild sialorrhea.

Sensation

Superficial sensation intact, he had decreased proprioception and kinesthesia in the upper limbs.

Motor Function

Resting tremor "pill rolling". Cogwheel rigidity pronounced in the upper extremities and mild-moderate rigidity in the trunk and lower extremities. Bradykinetic movement, dysmetria and mild-moderate difficulty with rapid alternating movement.

Range of Motion

Decreased range of motion, limited shoulder flexion and elbow extension. No contractures were noted.

  • Thoracic Rotation L/R: 20/18
  • Cervical Rotation L/R: 74/72
  • Shoulder flexion L/R: 125/120
  • Elbow flexion L/R: 130/127
  • Hip flexion 100 b/l
  • Hip extension 3 b/l
  • Knee flexion 130 b/l
  • Knee extension 5 b/l

Strength

Decreased strength of the upper limb, specifically at the shoulder and slight weakness of the elbow, hip and knee. Fatigue noted with sustained contractions.

  • Bilateral shoulder flexion: 3+/5
  • Bilateral elbow flexion: 4/5
  • Bilateral hip flexion: 4/5
  • Bilateral knee flexion: 4/5

Balance/Gait

His sitting balance was good but his standing balance was moderate during Mini-BESTest. He was able to transfer his weight side to side and forwards and backward[5].

  • Mini-BESTest: 22/28

During Timed Up and Go, asymmetrical gait, with poor hip extension, minimal trunk rotation, decreased step length and diminished arm swing. When turning, slight shuffling of gait and hesitation around the cone [6].

  • Timed Up and Go – 17 seconds
  • Timed Up and Go (without quad cane) – 20 seconds

Standardized Assessments

Towards the end of the physical examination, the patient started to experience an increase in symptoms specifically with tremors. Ted's medication had started to wear off indicating that he was in the "off time".

Unified Parkinson’s Disease Rating Scale [7][8]

  • Part 1: 2
  • Part 2: 20
  • Part 3: 55
  • Part 4: 9
  • Total = 86

Modified Hoehn-Yahr Scale: Stage 3[9]

Clinical Impression

Physiotherapy Diagnosis

The patient is a 54 year old retired carpenter that has recently been diagnosed with Parkinson’s disease, and was referred to outpatient physiotherapy for a home exercise program as well as guidance with managing his condition. He displays issues with gait including difficulty initiating movements, navigating narrow spaces and hesitates with turning, has reduced cervical and thoracic rotation, ROM in the; shoulder, elbow, hip and knee along mild postural deficits. The patient has expressed his concern with not being able to continue participating in dance classes with his wife. He additionally presents with cogwheel rigidity in both upper extremities, a moderate resting tremor, and some issues with coordination, that are impairing his ability to help his wife, who has Alzheimer’s, around the house, as well as working on small projects.

Problem List

  • Some issues with gait including difficulty initiating movements, navigating narrow spaces, and hesitates with turning - the patient is concerned this may limit his ability to participate in dancing with his wife
  • Increased stiffness and decreased range of motion (shoulders, hips, and knee ROM)
  • Mild thoracic kyphosis and a stooped posture in both sitting and standing
  • Cogwheel rigidity in upper extremities
  • Bilateral, moderate resting tremor in the upper extremities
  • Some issues with coordination and UE goal-directed aiming accuracy
  • Jerky movements in his dominant arm and hand are limiting him from working on small carpentry projects, as well as helping his wife around the house

Intervention

Goals were planned in collaboration with the therapy team, patient and family. Ted was encouraged to keep a diary of his "off times" that would outline[10]:

  • times of day when taking his Parkinson’s medication
  • times of day when he is able to control his symptoms
  • and, which symptoms tend to re-emerge during the day and when

Patient-Centred Goals

  1. Initiating movement & turning efficiency – Increase TUG score to < 15 seconds by the end of the training program.
  2. Improve stiffness
    1. Increase shoulder flexion and abduction by 5º by week 2 of the training program
    2. Increase thoracic and cervical spine rotation by 5º by week 2 of the training program.
  3. Improve coordination and proprioception in UE
    1. Be able to complete 10 consecutive goal-directed aiming movements with little to no error by week 2 of training program
    2. Increase Mini-BESTest score of activity #8, and #9 from moderate (1) to normal (2) by the end of the training program.
  4. Be able to participate in an hour of dancing once a week with his wife.
  5. Be able to better navigate through challenging spots in his house without freezing in order to best care for his wife.

4-week Training program, supervised by a certified LSVT BIG physical therapist

  1. 16 1-hour sessions of supervised training (4x/week)
  2. Home Training program throughout

1-hour sessions that are one-to-one with the therapist, and the emphasis is to encourage Ted to focus on making his movements feel and look big. The tasks are also encouraged to be performed at an 80% max effort (this will be defined on a 10-point VAS scale, 8/10 will depict the 80% required) in order to meet the high-intensity demands of the program.

Supervised Training

  1. Task 1 & 2 – Standardized whole-body movements with maximal-amplitude, repetitive, multidirectional movements
  2. Task 3 – Individual goal-directed ADL exercises
Task 1 + 2 Task 3
Exercises Seated and standing exercises:

Stepping and reaching in all directions, upper and lower limb involvement, trunk rotations, full ROM movements

Eg.

In addition, reps will be counted out load to help address any hypophonia development

Goal directed aiming exercises, smooth movement endurance exercises, dexterity exercises, obstacle gait training exercises, balance exercises

Eg. Pattern directed movements, line dancing to musical pattern, fast and big walking with large/narrow spaces, lunge to hit targets, step ups onto foam surface, big walking to stations to sign name on paper

FITT Principles F: 8-10 reps each side

I: 80% max effort (8/10 on VAS)

T: Large dynamic functional whole-body ROM exercises

T: 30 min./1 hr session

F: 3 stations of 2 exercises, 6 x 90sec alternating between both exercises

I: 80% max effort (8/10 on VAS)

T: Endurance & dynamic functional goal-directed exercises

T: 30min./1hr session

Home Training

In addition to their supervised training, completing the above exercises 1x a day on days they complete a supervised session + 2x a day on days without supervised sessions [3].

Education

  • Parkinson’s Disease education
    • Akinesia, hypokinesia, bradykinesia
    • Effects on gait, posture & postural instability, motor coordination, tremors & muscle rigidity
    • Self-management of on-off times
    • Encouragement to continue activities of daily living and hobbies within limits
  • More importantly: how rehabilitation will have a positive impact on the progression of his disease
    • Evidence-Based outcomes of the LSVT-Big program
    • Inform him of resources that include PD group classes he could also become a part of
    • Get his family involved and inform them of the progression of the disease, any resources and assistance if needed.

Outcomes

The patient’s UPDRS score did improve by 10 points, with the majority of improvements noted in Part II (Motor aspects of Experiences of Daily Living) and Part III (Motor Examination).

Unified Parkinson’s Disease Rating Scale

  • Part 1: 2
  • Part 2: 16
  • Part 3: 50
  • Part 4: 8
  • Total = 76

Improvements noted in Part 2 are due to changes in ability to successfully engage in hobbies, bed mobility, tremor, walking and balance, as well as freezing, while improvements seen in Part 3 are linked primarily to improvements in rigidity, gait and tremor. There was a slight reduction in time in overall time in dyskinesias as well.

The patient’s TUG score also improved to 16 seconds with the quad cane. Although this still remains slower than the goal of <15 seconds to decreased falls risk, and is below the minimum clinically important difference (MCID) for the TUG, the patient does show some improvements in overall balance and confidence while completing the measure. Further training should focus further on compensatory movements as well as the necessity for cueing during the initiation of movements.  

Additionally, there were improvements noted in all range of motion values targeted within the patient's rehabilitation goals:

  • Thoracic Rotation L/R: 23/21
  • Cervical Rotation L/R: 78/75
  • Shoulder flexion L/R: 128/125
  • Elbow flexion L/R: 130/127
  • Hip flexion 100 b/l
  • Hip extension 3 b/l
  • Knee flexion 130 b/l
  • Knee extension 5 b/l

Achieving his goal, the patient's Mini-BESTest score of activity #8, and #9 improved from moderate (1) to normal (2) by the end of the training program.

Finally, outside of quantitative outcome measures, nearing the end of the training program the patient is displaying marked improvements in confidence and reduced generalized worry. He appears brighter and more optimistic on entering his in-person training sessions, reports that his home exercise program is going extremely well, and is elated to still be dancing and able to help his wife[11].

Discussion

Parkinson's Disease (PD) is accompanied by a vast amount of clinical presentation symptoms that can impact the lives of many Canadians as it progresses. Fortunately, through sound scientific research on effective medication coupled with the advancements we are seeing in evidence-based practice for the treatment of PD, the rehabilitation community has been able to begin to tackle intervention strategies for Parkinson's with success. There have been numerous cases, as seen with the case of Ted, that have been shown to slow down disease progression while also improving patients' quality of life through intervention techniques aimed at dual-task/functional exercises and education. Physiotherapists play a crucial role in the rehabilitation of Parkinson's throughout the many stages of progression. The use of effective communication with all stakeholders involved in each case is imperative for a positive rehabilitation experience for the patient. Stakeholders include the patient, their family members, and other members on the inter-disciplinary team you will be working with daily. No treatment session will be the same, medications might change, and other health issues might arise and take precedence. Therefore it is extremely crucial that everyone on the inter-disciplinary team is up-to-date on the latest changes in the patient status. The use of education, exercise, and evidence-based interventions like LSVT Big, patients can improve their functional mobility, strength, and coordination. More importantly, patients with PD can take back their independence and confidence in being able to do ADLs and other activities that are important to them to significantly improve their quality of life, as seen with Ted. By helping your patient achieve their intervention SMART goals, in addition to sharing a strong therapeutic alliance focused on using a biopsychosocial approach, physiotherapists can have a truly positive impact on the lives of patients with Parkinson's.

Self-study questions

1. What are typical clinical presentations seen in patients with Parkinson's disease?

  • a.   Bradykinesia and hyperkinesia
  • b.   Bradykinesia and hypokinesia
  • c.   Rigidity
  • d.   All the above
  • e.   B and C

2. In using the movement program LSVT-Big to target motor symptoms in PD, what is the effective dose recommended found in evidence-based practice?

  • a.   45 minute sessions, 2-3x a week for 4 weeks unsupervised
  • b.   supervised, 1 hour sessions, 4x a week for 4 weeks, with added home exercise program
  • c.    1 hour sessions, 2-3x a week for 6 weeks, supervised
  • d.   supervised, 1 hour sessions, 4x a week for 4 weeks, with no added home exercise program

3. You are progressing Ted towards discharge and would like to assess his risk of falling while ambulating. What is the most appropriate outcome measure to do so?

  • a.   The MiniBEST test
  • b.   The Unified Parkinson’s Disease Rating Scale
  • c.   The Timed-Up-And-Go test (TUG)
  • d.  The Modified Hoehn-Yahr Scale

Answers: 1. e, 2. b, 3. c

References

  1. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/parkinsonism/parkinson-eng.pdf
  2. 2.0 2.1 2.2 Perry, S. I. B., Nelissen, P. M., Siemonsma, P., & Lucas, C. (2019). The effect of functional-task training on activities of daily living for people with Parkinson`s disease, a systematic review with meta-analysis. Complementary Therapies in Medicine42, 312–321. https://doi-org.proxy.queensu.ca/10.1016/j.ctim.2018.12.008
  3. 3.0 3.1 Janssens, J., Malfroid, K., Nyffeler, T., Bohlhalter, S. and Vanbellingen, T., 2014. Application of LSVT BIG Intervention to Address Gait, Balance, Bed Mobility, and Dexterity in People With Parkinson Disease: A Case Series. Physical Therapy, 94(7), pp.1014-1023.
  4. McDonnell MN, Rischbieth B, Schammer TT, Seaforth C, Shaw AJ, Phillips AC. 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;32(5):607‐618.
  5. King, L. A., Priest, K. C., Salarian, A., Pierce, D., & Horak, F. B. (2012). Comparing the Mini-BESTest with the Berg Balance Scale to Evaluate Balance Disorders in Parkinson’s Disease. Parkinson’s Disease (20420080), 1–7. https://doi-org.proxy.queensu.ca/2012/375419
  6. Nocera, J. R., Stegemöller, E. L., Malaty, I. A., Okun, M. S., Marsiske, M., Hass, C. J., & National Parkinson Foundation Quality Improvement Initiative Investigators (2013). Using the Timed Up & Go test in a clinical setting to predict falling in Parkinson's disease. Archives of physical medicine and rehabilitation, 94(7), 1300–1305. https://doi.org/10.1016/j.apmr.2013.02.020
  7. Brusse KJ, Zimdars S, Zalewski KR, & Steffen TM. (2005). Testing functional performance in people with Parkinson disease. Physical Therapy85(2), 134–141.
  8. Goetz CG, Tilley BC, Shaftman SR, Stebbins GT, Fahn S, Martinez-Martin P, Poewe W, Sampaio C, Stern MB, Dodel R, Dubois B, Holloway R, Jankovic J, Kulisevsky J, Lang AE, Lees A, Leurgans S, LeWitt PA, Nyenhuis D, & Olanow CW. (2008). Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Movement Disorders, 23(15), 2129–2170. https://doi-org.proxy.queensu.ca/10.1002/mds.22340
  9. Skorvanek, M., Martinez-Martin, P., Kovacs, N., Rodriguez-Violante, M., Corvol, J-C.,… & Taba, P. (2017). Differences in MDS-UPDRS Scores Based on Hoehn and Yahr Stage and Disease Duration. Movement Disorders Clinical Practice. Retrieved from https://www.movementdisorders.org/MDS-Files1/Education/Rating-Scales/Skorvanek_et_al-2017-Movement_Disorders_Clinical_Practice51.pdf
  10. https://www.epda.eu.com/about-parkinsons/symptoms/motor-symptoms/wearing-off-and-motor-fluctuations/
  11. Ebersbach, G., Ebersbach, A., Edler, D., Kaufhold, O., Kusch, M., Kupsch, A. and Wissel, J., 2010. Erratum: Comparing exercise in Parkinson's disease-The Berlin LSVT®BIG study. Movement Disorders, 25(14), pp.2478-2478.