Parkinson's Disease: A Case Study

Abstract

This fictional case study is a 68 year old retired farmer (female) who has been diagnosed with early stage idiopathic Parkinson's Disease and received a referral for physiotherapy. The case study documents her intake assessment until 12 weeks follow up and a summary of the major outcomes.

Client Characters

Gail is a 68 year old female. She is a retired farmer who lives at home alone with her dog. Gail’s husband passed away 5 years ago. She experienced a minor fall (~3 months ago) after tripping over her dog and landed on an outstretched right hand, leading to wrist pain. She saw her family doctor regarding her wrist, but also complained of some recent trouble with balance and a small hand tremor. She was referred to a neurologist and diagnosed with early stage idiopathic Parkinson’s Disease. She received a referral for physiotherapy to perform a falls risk assessment, maintain her functional status, and address her concerns regarding the condition.

Examination Findings

The patient had their intake assessment on May 9th, 2020.

Subjective

• Patient Profile (PP): 68 y/o female
• History of Present Illness (HPI): Diagnosis of idiopathic Parkinson’s Disease 1 month ago, left hand tremor (~5 months), right hand dominant and decreased handwriting size (~5 months), decreased balance (~1 year)
• Past Medical History: Right wrist injury (~3 months ago, resolved), Depression
• Medications: Currently none, received prescription and education for Levadopa (doesn’t feel she needs it yet), advil for headaches when needed
• Health Habits: Non-smoker, no longer drinks alcohol (~3 years)
• Psychosocial: Patient describes feeling lonely, isolated, and frustrated with diagnosis. Showing signs of depression. She has avoided going to see her friend due to feeling unsteady, and fear of falling (~3 months). Daughter lives ~2 hours away, and visits 1-2 times/month.
• Home: Bungalow, lives with dog, 4 stairs into house with railing,10 stairs to basement with railing (laundry). Bathroom has large shower/bathtub with non-slip mat but no railing.
• Previous Functional Status:
  • Prior to onset of PD symptoms (decreased balance and tremor): able to walk about ~200m to her friends house, gardening, performed ADLs independently, driving often (grocery store, recreation centre)
  • Prior to husband passing (~5 years ago): attended dance classes, was very active with farm work
• Current Functional Status
  • Since onset of PD symptoms: Drives when necessary but less confidence with reaction time, less confident walking outside, no issues with dressing/bathing, no problems with stairs, no problems with bed mobility
• Imaging: MRI scheduled for next week to rule out other causes of symptoms.
• Precautions/Contraindications: Depression, lack of social support, right wrist injury (~3 months ago)

Objective

• General: Slight masked face, slight muscular deconditioning, mild dysarthria, mild left resting hand tremor which increased while discussing history of diagnosis
• Posture: Moderate kyphotic forward head posture
• Gait: Mild bradykinesia

AROM:

• U/E: Limited bilateral shoulder flexion and abduction L>R
• Trunk: Limited in bilateral rotation
• L/E: Limited in bilateral hip extension, bilateral dorsiflexion (non-WB) L>R
• All other ROM WNL

PROM:

• U/E: Limited bilateral shoulder flexion and abduction L>R
• L/E: limited in bilateral dorsiflexion (non-WB) L>R
• All other ROM WNL

**Some limits due to mild rigidity (cogwheel)

Strength:

• Grip strength: R hand 18kg, L hand 20kg
• Overall strength: R 4+/5, L 4/5
  • Apparent weakness in antigravity muscles (back and neck extensors, hip extensors, quads, hip flexors)

Sensation: U/E and L/E intact

Neurological testing (myotomes, dermatomes, UMN tests, reflexes): normal

Tone: normal

Self-Reported Outcome Measures:

• Patient Health Questionnaire (PHQ-9): 12
• Parkinson's Disease Questionnaire (PDQ-39): 38/156 = 24%
  • Most affected areas: mobility, emotional well-being, social support
• Activities-Specific Balance Confidence Scale (ABC Scale): 65%

Outcome Measures:

• Timed Up and Go (TUG): 13.2 seconds
  • With cognitive task (counting backwards from 100 by 3): 13.7 seconds
  • With dual motor task (carrying glass of water in R hand): 15 seconds
• Berg Balance Scale (BBS): 40/56
  • Most affected areas: tandem stance, turning 360 degrees, standing with feet together, standing with eyes closed

Clinical Impression

The patient is a 68 y/o female with idiopathic early stage PD. Her subjective interview indicated that she is independent in her ADLs, but she is concerned regarding her balance and ability to participate in some activities. She also has a history of depression. Major clinical findings from the objective assessment revealed mild bradykinesia, mild deconditioning, decreased right hand strength (could be reflective of recent wrist injury), resting tremor in left hand, kyphotic posture, and decreased ROM (shoulders, hips, ankles).

Self report measures revealed a moderate score for depression (PHQ-9 score of 12)(Chagas et al), and moderate confidence on the ABC scale (Raad et al). She demonstrated only mild impairments due to PD on the PDQ-39 scale (Ability lab- PDQ-39), and areas with the lowest scores were mobility, emotional well being, and social support. These findings indicate that her lack of confidence and depressive symptoms may be leading to decreased participation in activities. There were no indicators of impaired cognition during the assessment and based on her responses to the PDQ-39.

This patient may be at an increased risk of falls due to decreased strength of anti-gravity muscles, and relevant outcome measures. Her TUG score was 13.2s (above cut score for PD of 12s), and TUG with dual motor task score was 15s (above cut score for PD of 13.2s) (Shumway-cook + Physiopedia-TUG). A BBS score <45 points indicates risk of falling (Physiopedia, berg), and this patient scored 40 points. These findings indicate the need to include balance and gait components in her treatment plan.

Mrs. Brown, who received a recent diagnosis of PD is otherwise generally healthy and attempting to remain active, however this has been limited over the past few months by her fear of falling and recent onset of depressive symptoms. She is a good candidate for physiotherapy treatment, with involvement of other healthcare professionals.

Problem List

1. Depressive symptoms
2. Fall risk and decreased confidence
3. Resting tremor L hand
4. Mild bradykinesia
5. Kyphotic posture
6. Decreased balance
7. Muscle deconditioning
8. Mild dysarthria
9. Decreased ROM

Intervention

Patient Goals

• Short Term Goals: Within 4 weeks Gail will...
  1. Improve ABC score from 65% to 75%.
  2. Walk to friend's house (200m one way) using Nordic walking poles.
  3. Attend dance program at the recreation center 2x/week beginning in 2 weeks.
• Long Term Goals: Within 12 weeks Gail will...
  1. Improve BBS from 40 to 47.
  2. Walk her dog for 30 minutes around the neighborhood.

Treatment Plan

	Frequency	Intensity	Time	Rationale
Education Role of the Physiotherapist (PT) Energy conservation methods Environmental modifications	During her initial appointment with check ins as needed	As appropriate	Ongoing	To ensure understanding of the role of PT, the purpose and effectiveness of her program, increasing compliance to her program while promoting her safety.
Gait Nordic walking Musical cueing	4 days/week	Light intensity	400m total	Problem list (2,4,6) Training of gait and balance in the early stages of PD is effective in its prevention of falls (Paul et al). Nordic pole walking has been found effective in improving balance, postural control, movement coordination, walking ability, and positively affecting socialization (Bang et al). Musical cueing can improve gait through improvements in speed of gait, and length of stride (Bella et al). These aspects also address Mrs. Brown’s decreased level of confidence.
Balance Training From BBS: Tandem stance Turning 360 degrees Standing with feet together Standing with eyes closed Examples (tandem stance, visual cues, balance boards, single leg stance)	In clinic 1x/week for the first month At home 1x/week for the first month To progress to be functionally included in her everyday	Working within the limits of her stability	30 minutes
Community Dance Program	2x/week	Moderate intensity	1hr	Problem list (1, 2, 4) Participation in dance for patients with PD can lead to improvements in balance and motor impairment helping decrease the risk of falls, as well as the socialization aspect of this activity is positive for overall quality of life (shanahan et al).
Strengthening General strengthening - Kitchen sink exercises Grip strength Postural strengthening/Motor control	3x/week	60% of 1RM	3 sets of 10	Problem list (2, 5, 6, 7) When gait and balance training are combined with postural motor control learning they are effective in the prevention of falls (Paul et al). As well, lower extremity strengthening can help to improve balance more so than balance training alone, which can further help decrease her risk of falls (Keus et al). Mrs. Brown’s grip strength appears to be a lasting limitation from her fall and strengthening here could ensure that she gains her full functioning in this wrist which can assist in her independence and activities.
ROM Shoulder Hip Dorsiflexion Trunk rotation	3x/week	Reach a point where you can feel the stretch but not past the point of pain	20 second static stretch for 3 sets OR 60 second dynamic stretch	Problem list (2, 9) Improving Mrs. Brown’s ROM can translate into her gait and balance training and contribute to her independence in performing her ADLs (Samyra et al).

Note:

• This program was developed to enhance Mrs. Brown's life in these early stages of her PD and reflects her current abilities and functionality as she was previously quite active.
• The program was reviewed in clinic and progressed as needed throughout treatment.

Inter-professional Health Team (NICE & Pirtosek et al)

• Already involved:
  • Family doctor
  • Neurologist
• To be involved:
  • Occupational Therapist: Driving assessment, Home assessment (bathroom specifically)
  • Psychologist: Regarding depressive symptoms
  • Speech Language Pathologist: Regarding dysarthria noted
  • Involvement in a PD support group