Parkinson's Management: Pandemic-related Deconditioning - Case Presentation Roy
Background[edit | edit source]
Parkinson’s disease is the second most common neurodegenerative disease in the older population, surpassed only by Alzheimer’s disease. Parkinson’s is associated with difficulties in walking, balance, dual tasks and cognitive function which become more pronounced as the disease progresses. Progression of Parkinson’s is also associated with a decrease in function and mobility as well as an eventual loss of independence in activities of daily living (ADL) (walking, dressing, transferring in and out of bed, housework, shopping, meal preparation), negatively impacting the quality of life (QoL) of the individual with Parkinson’s. Individuals with Parkinson’s are also at an increased risk for falls which poses a serious safety concern. Treatment of Parkinson’s is not aimed towards curing the disease but rather to control the symptoms in order to maintain optimal ADL, participation and quality of life. Physical activity and exercise are beneficial for individuals with Parkinson’s as it has been shown to impact the rate of symptom progression, improve their physical performance (gait, muscle strength, cardiovascular endurance) and enhance their QoL. Following the European guideline for Parkinson’s, physiotherapists are encouraged to focus exercise programs on functional-task training in order to best improve impaired tasks and ADL. Exercise has also been shown to improve cognition and depression, symptoms which become more evident as the disease progresses.
The progressive nature of Parkinson’s often leads to decreased function and mobility in individuals with Parkinson’s which inadvertently results in a tendency to adopt a more sedentary lifestyle involving low levels of physical activity. The fear of falling, which is often experienced by individuals with Parkinson’s, further contributes to increased sedentary time. Inactivity and a sedentary lifestyle is of particular concern in the Parkinson’s population as it is directly associated with their functional ability and QoL. The emphasis is therefore on promoting a more active lifestyle with high levels of physical activity and regular exercise in the Parkinson’s population which has been shown to have a protective effect on Parkinson’s.
A compromised health care system and the lock-down restrictions implemented during the COVID-19 pandemic has had a vast impact on the mental health, physical activity and QoL of individuals with Parkinson’s. Many patients reported worse stress, depression, anxiety, physical activity and QoL during the COVID-19 pandemic compared to pre-lockdown. This brings us to the first patient in this case report series, Roy, whose de-conditioning during the pandemic resulted in an increased number of falls and increased dependence on his caregivers.
Case Presentation of Roy[edit | edit source]
Past History[edit | edit source]
Roy is an 82-year widower who lived alone in a house at the time of his initial consultation in 2019. He is a retired painter and decorator with arthritic changes and limited range of motion in his neck and shoulder girdles. Apart from a diagnosis of Parkinson’s in 2017, Roy was otherwise well, leading a full social life independently visiting friends and family (son, daughter and their families), and also walked a lot for pleasure. As he had stopped driving several years ago, his daughter did the heavy shopping with him, and also any major house cleaning.
Roy first came to physiotherapy in April 2019 with the following concerns:
- A worsening of low-grade chronic back and shoulder girdle ache
- Noticeable changes to his posture and balance. At that time, however, there were no major falls, as Roy had started to hold onto furniture and other objects if he felt unsteady.
- A general reduction in energy that he did not put down to ‘old age’
The assessments and treatments at that stage included:
- The Tragus-to-wall test to review ability to alter posture from his default position
- Strength testing of the upper body (using grip strength), and lower body (with the 5 times sit to stand).
- Balance with the 4 Stage Balance Test
- Gait using the Tinetti gait score (version 7).
Treatment mainly focussed on:
- Regaining Roy’s flexibility and postural alignment when moving about during a monthly therapy session
- Motivating Roy and the family to push the pace of short walks to work his cardio-respiratory system
- A general programme of body strengthening exercises to maintain functional strength.
Roy demonstrated a steady improvement over a six-month period until he experienced some general health setbacks in September 2019. The period of recovery, along with the effect of the restrictions his family placed on mobility due to their concerns for his safety after a couple of falls when out, left Roy de-conditioned. By November 2019, with fortnightly sessions of physiotherapy, Roy started to regain some of his fitness and strength, and even when he did have another fall in December 2019, Roy was able to crawl to a coffee table and get up unassisted.
Current Presentation[edit | edit source]
The first lockdown in the United Kingdom because of the COVID-19 pandemic (March – July 2020) saw vulnerable older people (with multi-morbidities) asked to stay indoors, creating a recipe for further de-conditioning. This added to Roy’s state of frailty (age, gender and medical conditions) as he did not know how to substitute his walking activity for another. Increasing sedentary behaviour in addition to the loss of activity meant that Roy became less fit and weaker. His Parkinson’s symptoms worsened and in May 2020 he fell three successive times in a week - always forwards during a freezing episode when turning. This affected his confidence, as he was unable to get up off the floor each time. Roy’s daughter and grandson took turns to stay with Roy over a 24 hours/day period for a few weeks because he was so unsteady on his feet and needed full care and help in all activities. At that time, he was assessed at home by a therapy team from the National Health Service (NHS), who were able to provide equipment and adaptations to Roy’s house and put some social service support into place.
In June 2020, Roy returned to physiotherapy at the clinic, consulting with Dr Ramaswamy once every two weeks, and the NHS physiotherapists in the week between, resulting in weekly physiotherapy over an eight-week period. On consultation, it became evident that there was both a physical de-conditioning issue as well as a decline in cognitive function. Roy was finding simple instructions harder to understand, and when he did comprehend what was being asked, he was slow in his physical response to the request. In addition to this, his poor memory meant he was unable to remember exercises to do at home, necessitating the help of his family. Following an assessment at the Memory Clinic in October 2020, Roy was diagnosed with Parkinson’s with dementia.
The goals of physiotherapy have therefore already changed to also include educational sessions with the family, which will be the focus for the Case report.
Assessment[edit | edit source]
In the presentation Dr Bhanu Ramaswamy will assess Roy using the following tests:
- Single sit-to-stand test 
- Five Times sit-to-stand test 
- 30 second sit-to-stand test
- Timed up and go test
- Dual-task Timed up and go test including motor-on-motor and cognitive-on-motor tasks 
Remember that in this case, the two tests recorded in the clinical video footage were used to assess Roy’s performance and capacity in order to decide on treatments and how to use what we had seen to educate the family about the changes in his cognition. There is no ‘post-treatment’ assessment video, as the tests were not used as a means to measure outcome.
Resources[edit | edit source]
- The Clock Yourself App
- Plummer P, Eskes G. Measuring treatment effects on dual-task performance: a framework for research and clinical practice. Frontiers in human neuroscience. 2015 Apr 28;9:225.
- Parkinson's - Physiotherapy Referral and Assessment
- Parkinson's - Physiotherapy Management and Interventions
- Parkinson's - Anatomy, Pathology, Prognosis and Diagnosis
- European Physiotherapy Guideline for Parkinson’s Disease
References[edit | edit source]
- Perry SI, Nelissen PM, Siemonsma P, Lucas C. 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 medicine. 2019 Feb 1;42:312-21. DOI: 10.1016/j.ctim.2018.12.008
- Ellingson LD, Zaman A, Stegemöller EL. Sedentary Behavior and Quality of Life in Individuals with Parkinson’s Disease. Neurorehabilitation and neural repair. 2019 Aug;33(8):595-601. DOI:10.1177/1545968319856893
- Hunter H, Lovegrove C, Haas B, Freeman J, Gunn H. Experiences of people with Parkinson's disease and their views on physical activity interventions: a qualitative systematic review. JBI Evidence Synthesis. 2019 Apr 1;17(4):548-613. DOI: 10.11124/JBISRIR-2017-003901
- Fasano A, Canning CG, Hausdorff JM, Lord S, Rochester L. Falls in Parkinson's disease: a complex and evolving picture. Movement disorders. 2017 Nov;32(11):1524-36. DOI: 10.1002/mds.27195
- von Rosen P, Hagströmer M, Franzén E, Leavy B. Physical activity profiles in Parkinson’s disease. BMC neurology. 2021 Dec;21(1):1-8. DOI: 10.1186/s12883-021-02101-2
- Urell C, Zetterberg L, Hellström K, Anens E. Factors explaining physical activity level in Parkinson's disease: A gender focus. Physiotherapy theory and practice. 2021 Apr 3;37(4):507-16. DOI:1080/09593985.2019.1630875
- Müller J, Myers J. Association between physical fitness, cardiovascular risk factors, and Parkinson's disease. European journal of preventive cardiology. 2018 Sep 1;25(13):1409-15. DOI:10.1177/2047487318771168
- Shalash A, Roushdy T, Essam M, Fathy M, Dawood NL, Abushady EM, Elrassas H, Helmi A, Hamid E. Mental Health, Physical Activity, and Quality of Life in Parkinson's Disease During COVID-19 Pandemic. Mov Disord. 2020 Jul 1;35(7):1097-9. DOI: 10.1002/mds.28134
- Slater LV, Gebska A, McCartney K, Rafferty MR. Designing a screening battery for exercisers with Parkinson’s disease. Disability and Rehabilitation. 2021 Feb 8:1-7. DOI:10.1080/09638288.2021.1883748
- Makizako H, Shimada H, Doi T, Tsutsumimoto K, Nakakubo S, Hotta R, Suzuki T. Predictive cutoff values of the five-times sit-to-stand test and the timed “up & go” test for disability incidence in older people dwelling in the community. Physical therapy. 2017 Apr 1;97(4):417-24.
- de Melo TA, Duarte AC, Bezerra TS, França F, Soares NS, Brito D. The Five Times Sit-to-Stand Test: safety and reliability with older intensive care unit patients at discharge. Revista Brasileira de terapia intensiva. 2019 Jan;31(1):27. DOI: 10.5935/0103-507X.20190006
- Petersen C, Steffen T, Paly E, Dvorak L, Nelson R. Reliability and minimal detectable change for sit-to-stand tests and the functional gait assessment for individuals with Parkinson disease. Journal of geriatric physical therapy. 2017 Oct 1;40(4):223-6. DOI:10.1519/JPT.0000000000000102
- da Silva BA, Faria CD, Santos MP, Swarowsky A. Assessing Timed Up and Go in Parkinson's disease: Reliability and validity of Timed Up and Go Assessment of biomechanical strategies. Journal of rehabilitation medicine. 2017 Nov 1;49(9):723-31. DOI:10.2340/16501977-2254
- Mollinedo I, Cancela JM. Evaluation of the psychometric properties and clinical applications of the Timed Up and Go test in Parkinson disease: a systematic review. Journal of Exercise Rehabilitation. 2020 Aug;16(4):302. DOI:10.12965/jer.2040532.266
- Viteckova S, Krupicka R, Dusek P, Cejka V, Kutilek P, Novak J, Szabo Z, Růžička E. The repeatability of the instrumented timed Up & Go test: The performance of older adults and parkinson’s disease patients under different conditions. Biocybernetics and Biomedical Engineering. 2020 Jan 1;40(1):363-77. DOI:10.1016/j.bbe.2019.12.001
- Plummer P, Eskes G. Measuring treatment effects on dual-task performance: a framework for research and clinical practice. Frontiers in human neuroscience. 2015 Apr 28;9:225. DOI: 10.3389/fnhum.2015.00225
- Vance RC, Healy DG, Galvin R, French HP. Dual tasking with the timed “up & go” test improves detection of risk of falls in people with Parkinson disease. Physical therapy. 2015 Jan 1;95(1):95-102. DOI:10.1.1.883.6123
- Zirek E, Huseyinsinoglu BE, Tufekcioglu Z, Bilgic B, Hanagasi H. Which cognitive dual-task walking causes most interference on the Timed Up and Go test in Parkinson’s disease: a controlled study. Neurological Sciences. 2018 Dec;39(12):2151-7. DOI: 0.1007/s10072-018-3564-2
- Çekok K, Kahraman T, Duran G, Dönmez Çolakoğlu B, Yener G, Yerlikaya D et al. Timed Up and Go Test With a Cognitive Task: Correlations With Neuropsychological Measures in People With Parkinson's Disease. Cureus. 2020;12(9):e10604. DOI: 10.7759/cureus.10604
- Centers for Disease Control and Prevention (CDC). 30-Second Chair Stand Test. Published 21 April 2021. Available from: https://www.youtube.com/watch?v=Ng-UOHjTejY [last accessed 7 May 2021]
- Centers for Disease Control and Prevention (CDC). The Timed Up and Go (TUG) Test. Published 21 April 2015. Available from https://www.youtube.com/watch?v=BA7Y_oLElGY [last accessed 7 May 2021]
- Mission Gait. Timed Up and Go (TUG) Variations. Published 23 June 2020. Available from: https://www.youtube.com/watch?v=s-BCK7T_BYI [last accessed 7 May 2021]