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

Original Editor - User:Isabelle Poulin Top Contributors - Isabelle Poulin, Jill Lutchman, Samantha Feldman, Kim Jackson, Joseph Scalia, Rishita Patel and Jaykob Price

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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.

Problem List

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

Body Structure/Function

• Decreased balance, even in the ON-stage of medication.
  • 48/56 on the BBS.
  • 20/28 on MiniBEST.
• Abnormal gait pattern.
  • Decreased gait speed (relative to his age; 10.5 seconds on TUG).
  • 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

• Decreased independence due to tremors, postural instability.
• Decreased function with activities of daily living (dressing, eating), instrumental activities of daily living.

Participation Restrictions

• 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

Short Term Goals

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

Education

• 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 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

• 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

• 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

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

• 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

• 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 - 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

• 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

• Within 5 weeks, Ken will improve dorsiflexion strength bilaterally, allow 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

The 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

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 to prevent falls. As he is experiencing difficulties with balance, he will be educated on the importance of falls prevention and recovery training. Lastly, 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.

Strength Training

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 strengthening. The table 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.

TARGET AREA	EXERCISE EXAMPLES	PARAMETERS
Postural muscles - back and neck extensors, hip extensors and flexors, knee extensors	Chin tucks (cervical retraction) - neck extensors Bird dog Bridging	10 reps x 2 sets, 3 minutes of rest in between sets
Weak upper extremity and lower extremity muscles affecting gait - ankle dorsiflexors (tibialis anterior), ankle plantarflexors (gastrocnemius, soleus), 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

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

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.

Gait Training

The main focus of gait training for Ken will involve using visual and auditory cues to help generate a more regular gait pattern. 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”) as needed for Ken. Auditory cues, such as walking with a metronome, at a specific speed, or walking to the beat of a song will also be used to improve Ken’s gait.

Balance Training

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 (Shen et al., 2016). 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. The table 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.

Area of focus	Exercises/Tasks
Improve specific components of the Berg balance scale and mini-BEST (each of the tasks will be performed 3-4 times/ week (2 days/ week at the clinic, 1-2 days/ week at home)

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).