Parkinson's Disease (PD): A Case Study

Original Editor - Akshay Misir Top Contributors - Akshay Misir, Gurshan Mann, Mohammed Ahmed, Kevin Jeyendran, Maxine Edos, Sara Bayanati, Pawmir Aminullah, Cindy John-Chu, Kim Jackson and Uchechukwu Chukwuemeka

Introduction

Parkinson’s Disease is a progressive neurodegenerative condition that is caused by the death of dopaminergic neurons in the pars compacta within the midbrain. The Pars compacta is a dopamine producing region located in the substantia nigra of the midbrain.(9) Dopamine is a neurotransmitter that is heavily involved in neural regulation of behavioral and physiological functions such as motivation, reward, coordination, balance, neuroendocrine control, and executive function.(10) Motor symptoms of PD include uncontrollable tremor, bradykinesia, balance deficit, postural dysfunction, and rigidity. (11) Non-motor symptoms include impaired memory, planning, mood (anxiety and depression), speech, smell, and sleep (insomnia) as well as fatigue and difficulty swallowing. (11)(12)

The purpose of this case study is to portray the positive effects of VR (Virtual Reality) on motor function and quality of life in patients living with PD. Previous research demonstrates the benefits of simulating external environments within the safety and comfort of a patient’s home on the efficacy of their rehabilitation program.(13) Triegaardt et al. completed a metanalysis of ten papers (N = 343) and systematic review of 27 papers (N = 688) to investigate the use of virtual reality (VR) intervention strategies for patients with PD. Although the underlying mechanism that is responsible for how VR is beneficial for patients remains unknown, their findings demonstrate that VR is associated with a variety of improvements to physical and mental health when used in a rehabilitation program. The different domains that Triegaardt et al. examined include stride length, gait speed, balance, coordination, cognitive function, mental health, quality of life and activities of daily living.(13) The current literature supports the active approach that incorporates various types of training including balance, endurance, strength, and flexibility. This case study will demonstrate how those training techniques play an important role in improving the motor function and quality of life in those living with PD.

Client Characteristics

Mrs. Tribianni is a 66 year old female who lives with her husband and dog in a two-storey house. Mrs. Tribianni is an elementary school teacher who teaches science and math. Prior to teaching children, Mrs. Tribianni was a competitive ballet dancer during her twenties. After she retired from dancing, she continued her passion by teaching ballet on the weekends. Approximately a year ago, Mrs. Tribianni noticed that her shoulder muscles were feeling stiffer than before and her hand would shake when she was relaxed. Mrs. Tribianni believed these issues were due to aging, so she did not consult her family physician until she had a fall. Mrs. Tribianni’s family physician referred her to a neurologist who diagnosed her with late-onset, stage 3 (middle stage) idiopathic Parkinson’s Disease. After her diagnosis, Mrs. Tribianni was referred to physiotherapy for balance, gait, and strengthening rehabilitation.

Examination Findings

Demographics

Full name: Mrs. Martina Tribianni  

D.O.B: July 23, 1956

Sex: Female

Languages spoken: English, Italian

History of present illness

Diagnosis: Late onset stage 3 (middle stage) idiopathic Parkinson’s Disease

Current symptoms:

Rigidity: Patient noticed stiffness in the right side of the body initially, she now claims she feels stiffness on both sides. Bradykinesia: Patient mentions that it takes her longer to walk her dog now

Micrographia: Patient mentions that her handwriting has become smaller.

Tremor: Patient mentions that her shaking hand tends to significantly decrease when performing voluntary movements. However, she mentions it becomes worse when she feels stressed or anxious.

Postural instability: Patient mentions she has had a couple falls while teaching dance to her students. Currently, an assistant is helping her demonstrate dance movements to her students instead.

Fatigue: Patient mentions that as the day progresses, she starts to feel lethargic.

Anosmia: Patient claims she can’t smell spices while she is cooking

Sensory symptoms: Patient mentions she has noticed some aching pain in her lower back

Dysphagia: Patient mentions that her swallowing difficulties has prevented her from eating certain foods due to a fear of choking.

Sleep behaviour: Patient claims she has difficulty falling asleep at night and she sometimes feels drowsy during the day

Past Medical History: Fracture of the 5th metatarsal when she was 15 yrs old due to dance (no complications; fully healed), ankle sprain 5 months ago due to a fall (resolved). Patient had 3 other falls with no significant injuries.

Medications: Dopaminergic therapy (Levodopa/Carbidopa)  

Health habits: No history of substance or alcohol abuse. Non-smoker. Patient mentions she drinks wine in social settings, once in a while.

Psychosocial: The patient mentions that she is experiencing feelings of sadness and frustration. Patient claims that her “shaking”, “heavy limbs”,  and fear of falling affect her ability to dance. Patient also mentions that her inability to smell different spices while cooking has left her feeling frustrated as cooking with her husband is one of her hobbies.

Social History: Elementary school teacher and dance teacher. Lives with husband and their dog in a two-storey house that has 4 stairs to enter the home, and 10 stairs to reach the second floor. Hobbies include dancing, cooking, going for hikes, and spending time with friends and family.

Intervention

Short term goals  

• Increase gait speed by 0.3m/s by the end of 3 weeks of treatment  

• Patient will be able to perform a tandem stance for at least 30s with minimal assistance within 4 weeks  

• Patient will increase strength in all bilateral shoulder movements to at least a grade 4/5 on the manual muscle testing scale by the end of 4 weeks

• Patient will increase strength in all bilateral hip and knee movements to at least a grade 4/5 on the manual muscle testing scale by the end of 4 weeks

Long term goals  

• Patient will be able to stand up and teach for at least 50% of the time within 3 months  

• Patient will be able to actively participate in playful activities with her dog in the next 4 months  

Strengthening Interventions

• Strengthening exercises are very important for our patient as they will challenge her muscles and help gain back strength. Our patient has experienced weakness post PD onset, and it is therefore crucial for our team to integrate a strengthening program to ensure that we prevent muscle atrophy. We will begin with light functional exercises and eventually progress these exercises by increasing resistance. Attached is the week 1 exercise program, the team will progress these strengthening exercises once the patient starts to comfortably perform the exercises below.

Stretching Interventions

• Stretching exercises are also extremely important to integrate into our patient’s treatment program as it will help increase her flexibility. Our patient presents with rigidity, so it is particularly important that we manage this and limit the muscle tone that she is experiencing by stretching out different muscle groups. Attached is the week 1 exercise program, the team will progress these stretches once the patient is comfortably performing the stretches below

Balance interventions

• Patient has trouble with a decreased base of support and scored lower than 52 on the Berg Balance scale, therefore exercises promoting balance and changing base of supports will help decrease risk of falls and increase confidence in themselves. In clinic, patient was given the following exercises and parameters; one leg stance with therapist guarding. Patient held this stance for 30 sec for 3 sets with the therapist nearby guarding. The other exercises done in clinic included crossover lateral steps with therapist guarding closely. Patient completed this 10 times in both directions for 2 sets.
• The home exercises program given to the patient included a tandem stance as well as a narrow stance on a pillow. The tandem stance was held for 30sec for 3 sets, 4x a week. The narrow stance on a pillow was also held for 30sec for 3 sets, 4x a week.

Aerobic/Endurance interventions

• Patient is only able to walk short distances before fatiguing and spends most of her teaching time sitting down. Therefore, providing endurance and aerobic training to the patient will help her be more functional and able to stand and walk further therefore targeting patient goals.
• As part of the home exercise program, the patient was given a marching and walking program. In the marching program the patient can perform in both sitting and standing depending on how patient feels that specific day. The goal is to complete these marches for 30 sec for 2 sets, 3x a week. This can also be done near a table or counter for support and balance purposes. The walking program given also progresses weekly, starting at 80m and progressing about 20m every week. Patient will perform both the marching and walking programs 3x a week.