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

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Introduction

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 relative to the 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 (physiopedia reference). There are extensive clinical presentations and patient challenges of LBD, including fluctuating cognitive deficits, impairments with movement, sleep, behaviour, mood, and memory (National institute on aging reference). 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

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) (Hudson, Lewis, Christensen, 2021). 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. 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 PD 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. 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

Subjective

Patient profile: 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: Patient 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 PD,  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.

Medications: (Boot et al., Mayo Clinic, RxList)

• 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: 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 (hasn’t been able to see them due to COVID-19).

Previous & Current Functional Status: Previously independent in all IADLs, currently he has stopped 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 and 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

Observation

• 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

• Gait speed: decreased relevant to his age.
• 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

• 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)

• 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).

Hand Grip Strength

Table 2: Ken’s Hand Grip Strength measured with a hand dynamometer taken upon initial assessment. Averaged over 3 trials, measured in kilograms.

	Left	Right
Average	32.5	35.5

Rigidity

• 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

• 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

• 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 MDS-UPDRS

TEST	SCORE
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

• MDS-UPDRS:
  • Part 1: Non-Motor Aspects of Experiences of Daily Living = 28
  • Part 2: Motor Aspects of Experiences of Daily Living = 26
  • Part 3: Motor Examination = 31
  • Part 4: Motor Complications = 5
  • Overall = 92

• Berg Balance Scale = 48/56
• Mini-BEST = 20/28
• Timed Up & Go = 10.5 seconds
  • Ken took 7 steps to turn 180°.

Clinical impression

Physiotherapy Diagnosis

Ken experiences rigidity and tremors, impaired motor control, and a decrease of independence affecting his function, balance, gait, and activities of daily living.

Resources

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).