Parkinson's Disease (PD): A Case Study
Abstract[edit | edit source]
This case study is regarding Parkinson’s Disease (PD) which is a neurodegenerative disorder that causes an impairment in the production of dopamine in the brain.The absence of dopamine results in various deficiencies in the motor, physiological, and behavioural state of this population. The objective of this case study is to explore the effectiveness of Virtual Reality (VR) on motor function and quality of life in patients living with PD. Recent evidence has shown positive outcomes in motor function, cognition, and mental health. The following case illustrates a 66 year old woman who is diagnosed with late-onset stage three idiopathic Parkinson’s Disease. She has been referred to physiotherapy by her neurologist and has partaken in an intervention in which a multi-faceted exercise programme consists of aerobic, resistance, and stretching movements. After three months of treatment, the patient was reassessed on all outcome measures, and specifically showed improvements in the BERG balance scale, improving her score to 53/56, an eight-point increase from her initial score, indicating her decreased risk of falling. The Timed Up and Go test was also reassessed and was completed in 11.2 seconds, which is also an improvement that indicates a lower risk of falling. Outcome measures of mini-BEST and dynamic gait index demonstrated no significant changes after interventions were implemented.
Introduction[edit | edit source]
Parkinson's Disease (PD) 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. Dopamine is a neurotransmitter that is heavily involved in the neural regulation of behavioural and physiological functions such as motivation, reward, coordination, balance, neuroendocrine control, and executive function. Motor symptoms of PD include uncontrollable tremor, bradykinesia, balance deficit, postural dysfunction, and rigidity. Non-motor symptoms include impaired memory, planning, mood (anxiety and depression), speech, smell, and sleep (insomnia) as well as fatigue and difficulty swallowing.
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 programme.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 programme. The different domains that Triegaardt et al (2020) examined include: stride length, gait speed, balance, coordination, cognitive function, mental health, quality of life, and activities of daily living. 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 motor function and quality of life in those living with PD.
Client Characteristics[edit | edit source]
Mrs. Tribianni is a 66 year old female who lives with her husband and dog in a two-storey house. She is an elementary school teacher who teaches science and math. Prior to teaching children, the patient 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. Her 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[edit | edit source]
Demographics[edit | edit source]
Full name: Mrs. Martina Tribianni (She/Her)
Date of Birth: July 23, 1956
Languages spoken: English, Italian
History of present illness[edit | edit source]
Diagnosis: Late-onset stage 3 (middle stage) idiopathic Parkinson’s Disease on the Hoehn and Yahr Scale
Current symptoms:[edit | edit source]
- Rigidity: The patient noticed stiffness in the right side of the body initially, she now claims she feels stiffness on both sides.
- Bradykinesia: The patient mentions that it takes her longer to walk her dog now.
- Micrographia: The patient mentions that her handwriting has become smaller.
- Tremor: The 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: The patient mentions she has had a couple of 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.
- Sensory symptoms: The patient mentions she has noticed some aching pain in her lower back.
- Dysphagia: The patient mentions that her swallowing difficulties have prevented her from eating certain foods due to a fear of choking.
- Sleep behaviour: The 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). The 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. The 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. She claims that her “shaking”, “heavy limbs”, and fear of falling affect her ability to dance. The 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 and dance teacher. Lives with her 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.
Previous Functional Status (prior to PD onset): The patient was able to independently play and walk her dog to the park from her house (500 m) without feeling tired. Able to demonstrate dance moves to her students at the dance studio.
Current functional Status (after PD onset): Patient mentions that both her limbs feel stiff and heavy. The patient mentions that this is especially apparent when she is trying to write on the chalkboard at work and when she is dancing. She mentions feeling “off balance” sometimes and has reported having 4 falls within the past several months. She claims she requires her husband’s assistance with some activities of daily living as well. The patient now walks shorter distances (100m) and takes breaks while walking her dog.
Objective status: General observation[edit | edit source]
- Posture: slightly stooped posture (flexion of the neck, trunk, hips, and knees). Kyphosis.
- Involuntary movements: Resting tremor (in both hands, but more apparent in right hand).
- Aids: The patient has a single-point cane
Objective status: Factors that may affect overall response[edit | edit source]
- Cognition: The patient is oriented
- Consciousness: Conscious
- Communication: signs of dysarthria are present. The patient has low voice volume and is slightly monotone.
Objective status: Factors that may affect the ability to move[edit | edit source]
- Active range of motion (AROM)
- Upper extremity: limited shoulder flexion in right and left shoulder
- Lower extremity: small limitation with hip flexion
- Passive range of motion (PROM)
- Upper extremity: limited shoulder flexion in right and left shoulder
- Lower extremity: small limitation with hip flexion
- Manual Muscle Testing (MMT)
- Upper extremity strength: All 3/5
- Lower extremity strength: All 3/5
- Myotomes, dermatomes, upper motor neuron test, and reflexes are diminished.
- Tone: Rigidity is present on both sides of the body
Objective status: Voluntary movement[edit | edit source]
Gait: Mild decrease of arm swing during gait, reduced stride length, reduced speed of walking, mild disability to turn suddenly, freezing of gait was seen during sudden turns
Self-reported Outcome Measures[edit | edit source]
Activities-Specific Balance Confidence - 55 /100.
Cut-off 69%. Therefore, a value lower than this is indicative of predicting falls.
Outcome Measures[edit | edit source]
- TUG (in seconds) - 14.8 seconds.
Since this is greater than 11.5 seconds (i.e. the cut-off score), she has a high risk of falling.
- BERG Balance Scale – 50/56.
A score of less than 52 indicates that she has a greater risk of falling. Patients experienced most difficulty with decreased BOS (i.e. feet closer together, tandem stance, and standing on 1 foot), turning around 360 degrees, and standing with eyes closed.
- Mini-BEST test - 18/32 .
The cut-off score is <20/32. Therefore, a score lower than this indicates an increased risk of falling.
- Dynamic gait index - 16/24.
The cut-off score is < 19/24 is indicative of an increased risk of falling. The patient appears to have minimal impairment when pivoting while walking and walking with the head turned both horizontally and vertically.
Results of diagnostic test [edit | edit source]
The diagnosis of PD is dependent on subjective history and a clinical examination rather than a definitive diagnostic test. Since, Mrs. Tribianni presents with the cardinal signs of PD (bradykinesia, rigidity, and postural instability) and has also benefited from dopaminergic therapy, a diagnosis of Parkinson’s Disease can be made.
Clinical Impression[edit | edit source]
Mrs. Tribianni is a 66-year-old female who has been diagnosed with late-onset stage 3 idiopathic PD. She has an overall decrease in strength (3/5 MMT in UE/LE) and slight limitations in bilateral shoulder flexion and hip flexion. Upon observation, Mrs. Tribianni presents with facial masking, dysarthria, a right-sided dominant resting tremor, and moderate kyphosis. With gait, she is showing signs of freezing, difficulty turning, and a reduced arm swing. Outcome measures utilized in the assessment (TUG, BERG balance scale, Mini-BEST test, Dynamic gait index, and Activities-Specific Balance Conditions) indicate that she is at an increased risk of falling. All things considered, she is presenting with the cardinal signs of PD which are bradykinesia, rigidity, and postural instability.
This has taken a considerable toll on Mrs. Tribianni’s psychosocial state. Due to the inability to partake and enjoy her hobbies of cooking and dancing, she has now recently taken on a much more sedentary lifestyle since her PD onset. She feels her arms and legs are too heavy and stiff to partake in her favourite activities such as walking her dog with her husband, dancing with her students, and cooking independently (she is still partaking in these activities but in a modified capacity i.e. breaks during dog walks, assistance with ADLs from husband, and instructing students rather than demonstrating). As a result, she is experiencing anxiety, frustration, and sadness due to her withdrawal from these activities. Furthermore, given her living situation, she is showing an increase in fatigue in and around her house, especially when climbing up and down the stairs.
Intervention[edit | edit source]
Short term goals [edit | edit source]
- 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 of 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 of 4/5 on the manual muscle testing scale by the end of 4 weeks
Long term goals [edit | edit source]
- 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[edit | edit source]
- Strengthening exercises are very important for our patient as they will challenge her muscles and help her gain back strength. Our patient has experienced weakness post PD onset, and it is, therefore, crucial for our team to integrate a strengthening programme to ensure that we prevent muscle atrophy. We will begin with light functional exercises and eventually progress these exercises by increasing resistance. Refer to figure 3 for the week 1 strengthening program, the strengthening exercises will be progressed once the patient is comfortable performing them.
Stretching Intervention[edit | edit source]
Balance interventions[edit | edit source]
- Mrs. Tribbiani has trouble maintaining balance with a decreased base of support and scored lower than 52 on the Berg Balance scale. Therefore, exercises promoting balance and BoS alterations should be incorporated into the treatment plan as they will help decrease the risk of falls and increase confidence in our patients. In the clinic, Mrs. Tribbiani was given exercises and parameters listed in Figure 5. These included the one leg stance and crossover lateral steps with the therapist guarding closely.
- The home exercises program given to the patient included a tandem stance as well as a narrow stance on a pillow (refer to Figure 5.).
Aerobic/Endurance interventions[edit | edit source]
- Mrs. Tribbiani 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, Mrs. Tribbiani was given a marching and walking program (refer to Figure 5.). In the marching program, the patient can perform the task in both sitting and standing depending on how she feels that specific day. 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.
Technology[edit | edit source]
Virtual reality (VR) is a safe computer-generated environment that allows patients to interact in a way that simulates a physical environment from the comfort of their own home. It provides patients with cognitive and motor experiences that mimic real-world situations by incorporating different senses such as vision, audition, and tactile touch. This feature of VR makes it an enriching intervention strategy for patients with Parkinson’s disease.
Triegaardt et al (2020) conducted a meta-analysis and systematic review which found that VR had positive outcomes in over a thousand patients with PD. These outcomes included stride length, gait speed, balance, coordination, cognitive function, mental health, quality of life, and activities of daily living. These findings suggest that virtual reality can be a valuable tool in neurorehabilitation.
As virtual reality is a new therapy for PD, the underlying mechanism of how it can improve PD symptoms has not been established. Thus, further research investigating the benefits of VR in neurorehabilitation is recommended.
Outcome[edit | edit source]
Mrs.Tribbiani was reassessed by the physiotherapist 3 months after her initial visit. The BERG balance Scale was administered once again and Mrs.Tribbiani improved her score by 7 from her initial assessment. She has now scored a 53/56 indicating that she is at a decreased risk of falling. Specifically, she has shown improvement in maintaining balance with a decreased BoS. She could now effectively maintain balance with her feet close together and when in a tandem stance. The therapists are extremely pleased with the progress made with regard to her balance and will continue to include balance interventions in her treatment plan going forward. The TUG test was also administered again and Mrs.Tribbiani completed this test in 11.2 seconds. This indicates that she is at a lower risk of falling and has greatly improved her balance and motor skills.
The MiniBEST was administered again and Mrs. Tribbiani’s score improved to a score of 23/32. This score is above the threshold of 20/32, meaning the risk of falling has significantly decreased. This increase in score indicates that Mrs.Tribbiani has improved her coordination and is more efficient with regard to her movements. In regards to the Dynamic gait index, Mrs. Tribbiani’s score increased to 21/24. This again was above the threshold score of 19, indicating that she has a significantly decreased chance of falling and has increased confidence when ambulating. The patient is more confident in themselves and moves much more smoothly when walking or transitioning from sitting to standing as well. Overall, Mrs. Tribbiani has shown significant improvements in the past 3 months.
Objectively, an increase in ROM was observed both passively and actively. Both shoulder flexion and hip flexion increased bilaterally, and this is greatly due to the stretching and ROM exercises that Mrs. Tribbiani has been performing over the past 3 months of treatment. Her passive ROM felt less resisted and end range was increased for all movements. The patient’s overall strength also increased as seen in her MMT scores. Mrs. Tribbiani’s upper extremity muscle groups increased to at least a 4/5, and this increase in strength can be attributed to the strengthening and endurance program designed by the therapist. The patient’s lower extremity muscle groups increased to a 4+/5, and she was able to walk over 250m without fatiguing. Mrs. Tribbiani seemed to really benefit from the exercise programs that were designed for her and will continue to participate in them to further improve her strength, gait, balance, and ROM.
Referral to other healthcare professionals [edit | edit source]
Due to the multi-faceted nature of PD, it is essential for a multi-disciplinary team to be involved to get the best outcomes for this population. There is a vast array of non-motor features of PD that need to be addressed. In Mrs. Tribbiani’s case, since she is attending a community-based rehabilitation programme and has been referred for a variety of issues, the rehabilitation facility will base their assessment and design a personalized multimodality therapeutic intervention
Psychiatrist:[edit | edit source]
Those who are diagnosed with PD are likely to develop psychological issues that can hinder their progression with their recovery. Especially true in Mrs. Tribianni’s case, she has developed a depressive mood and anxiety. Psychiatrists handle this by:
- Evaluating mental status and recommending the provision of psychosocial support and cognitive behavioural therapy
- Include family members or caregivers in this intervention
- Prescribe medications and other psychotherapies according to the patient’s needs
Speech Language Pathologist (SLP):[edit | edit source]
There are prevalent speech and swallowing disturbances that occur when one is diagnosed with PD. Though Mrs. Tribianni is in the early stages of these symptoms, taking on an SLP’s guidance as a preventative measure can help slow down their progression of them.
- Early detection is key to preventing communication issues down the road, and can even prevent aspiration pneumonia
- Uses evidence-based guidelines for the intervention, including recommendations that assist SLPs with the treatment of those with PD.
Social Worker:[edit | edit source]
Social workers have a central role in the team that handles patients with PD, as they are the first contact with the families when the consequences of PD become apparent.
- Helps patients recruit community and personal resources to improve their quality of life
- Improve/teach coping abilities that are uniquely tailored for the specific individual and family
- Usually guided with the work of the nurse, SLP, and neurologist).
Occupational Therapists (OTs):[edit | edit source]
OTs identify strategies that allow patients to continue on with activities they enjoy. Each person with PD is going to be unique in their goals, priorities, and lifestyles. As a result, OTs find suitable ways to improve the quality of life by implementing strategies.
- Build on the strengths of the patient and uses this to create a treatment plan that can boost morale and motivation
Discussion[edit | edit source]
Parkinson’s Disease is a progressive neurodegenerative condition associated with the dopaminergic nerves in the pars compacta, located within the midbrain. Dopamine has major implications on many behavioural and physiological functions, and a lack of this neurotransmitter can have detrimental motor and non-motor effects. In this fictional case study, we exhibited the presence of PD by determining patient examination findings and creating a hypothetical management plan.
Martina Tribianni is a 66-year-old elementary school teacher and ballet teacher who was diagnosed with stage 3 idiopathic PD. Completion of a physiotherapy assessment revealed rigidity, tremors, postural instability, fatigue, insomnia, dysphagia, and an abnormal sleep schedule. Her results from several objective measures, including the TUG, BBS, Mini-BEST test, and Dynamic gait index, indicated an increased risk of falling. The musculoskeletal exam indicated a lack of strength in both her lower and upper extremities, and a limitation in the bilateral shoulder and hip flexion. The effects of PD have left Mrs. Tribianni psychologically distraught, as she feels she has to live a much more sedentary lifestyle now. She is unable to participate in and complete the regular daily activities that she once was able to do. However, despite her findings, she remains optimistic to begin treatment and learn how to manage her symptoms effectively.
Based on the aforementioned examination findings, Mrs. Tribianni’s management plan will focus on balance, endurance, strengthening, and stretching interventions. Due to the low score on the BBS, she was prescribed exercises that worked on improving her stance. In Mrs. Tribianni’s daily life, she found she was fatiguing quicker and this had implications for her everyday life. Regarding her endurance interventions, standing marches and walking were both prescribed. She was given strengthening exercises to target overall weakness and stretching exercises to manage her rigidity.
Other neurological conditions related to balance impairments and motor dysfunction can benefit from the interventions applied in this case. Extrapolating the exercises in this case and progressing them can target different implications in a variety of patients. The interventions provided can improve the balance and gait of patients with neuromotor dysfunction. Furthermore, the strengthening programs can help deconditioned individuals regain strength and function. The stretching program can help individuals who experience muscle contracture and hypertonia. Due to the nature of PD, treatments are closely related to a multitude of other conditions and therefore can be generalized and modified to treat these other conditions.
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Kim SJ, Sung JY, Um JW, Hattori N, Mizuno Y, Tanaka K, et al. Parkin cleaves intracellular α-synuclein inclusions via the activation of calpain. Journal of Biological Chemistry. 2003;278(43):41890–9. DOI: https://doi.org/10.1074/jbc.M306017200
- ↑ 2.0 2.1 2.2 Alcaro A, Huber R, Panksepp J. Behavioral functions of the mesolimbic dopaminergic system: An Affective Neuroethological Perspective. Brain Research Reviews. 2007;56(2):283–321. DOI: 10.1016/j.brainresrev.2007.07.014
- ↑ 3.0 3.1 3.2 Triegaardt J, Han TS, Sada C, Sharma S, Sharma P. Correction to The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: Meta-analysis and systematic review in 1031 participants. Neurological Sciences. 2020;41(3):731–2. DOI: 10.1007/s10072-019-04212-8
- ↑ 4.0 4.1 4.2 Sveinbjornsdottir S. Sci-hub | the clinical symptoms of Parkinson's disease. Journal of Neurochemistry. [Internet]. [cited 2022May10]. Available from: https://sci-hub.se/10.1111/jnc.13691
- ↑ Kalia LV, Lang AE. Parkinson's disease. The Lancet. 2015;386(9996):896–912.
- ↑ Mayo Clinic. Parkinson’s Disease. Available from: https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/symptoms-causes/syc-20376055 (Accessed 5 May 2022).
- ↑ Fung VS, Burne JA, Morris JG. Objective quantification of resting and activated parkinsonian rigidity: a comparison of angular impulse and work scores. Movement Disorders: Official Journal of the Movement Disorder Society. 2000 Jan;15(1):48-55. DOI: https://doi.org/10.1002/1531-8257(200001)15:1<48::AID-MDS1009>3.0.CO;2-E
- ↑ 8.0 8.1 8.2 8.3 8.4 Jankovic J. Parkinson’s disease: clinical features and diagnosis. Journal of neurology, neurosurgery & psychiatry. 2008 Apr 1;79(4):368-76.
- ↑ Lee HJ, Lee WW, Kim SK, Park H, Jeon HS, Kim HB, Jeon BS, Park KS. Tremor frequency characteristics in Parkinson's disease under resting-state and stress-state conditions. Journal of the neurological sciences. 2016 Mar 15;362:272-7. DOI: https://doi.org/10.1016/j.jns.2016.01.058
- ↑ Chaudhuri KR, Healy DG, Schapira AH. Non-motor symptoms of Parkinson's disease: diagnosis and management. The Lancet Neurology. 2006 Mar 1;5(3):235-45. DOI: https://doi.org/10.1016/S1474-4422(06)70373-8
- ↑ Young Blood MR, Ferro MM, Munhoz RP, Teive HA, Camargo CH. Classification and characteristics of pain associated with Parkinson’s disease. Parkinson’s Disease. 2016 Oct 5;2016. DOI: https://doi.org/10.1155/2016/6067132
- ↑ Kalf JG, De Swart BJ, Bloem BR, Munneke M. Prevalence of oropharyngeal dysphagia in Parkinson’s disease: a meta-analysis. Parkinsonism & related disorders. 2012 May 1;18(4):311-5. DOI: https://doi.org/10.1016/j.parkreldis.2011.11.006
- ↑ Tjaden K. Speech and swallowing in Parkinson’s disease. Topics in geriatric rehabilitation. 2008;24(2):115. DOI: 10.1097/01.TGR.0000318899.87690.44
- ↑ DeMaagd G, Philip A. Parkinson’s disease and its management: part 1: disease entity, risk factors, pathophysiology, clinical presentation, and diagnosis. Pharmacy and therapeutics. 2015 Aug;40(8):504. PMID: 26236139
- ↑ Activities-Specific Balance Confidence Scale . Shirley Ryan AbilityLab. 2022 [cited 10 May 2022]. Available from: https://www.sralab.org/rehabilitation-measures/activities-specific-balance-confidence-scale#parkinsons-disease
- ↑ Timed Up and Go. Shirley Ryan AbilityLab. 2022 [cited 10 May 2022]. Available from: https://www.sralab.org/rehabilitation-measures/timed-and-go#parkinsons-disease
- ↑ Berg Balance Scale. Shirley Ryan AbilityLab. 2022 [cited 10 May 2022]. Available from: https://www.sralab.org/rehabilitation-measures/berg-balance-scale
- ↑ Mini Balance Evaluation Systems Test. Shirley Ryan AbilityLab. 2022 [cited 10 May 2022]. Available from: https://www.sralab.org/rehabilitation-measures/mini-balance-evaluation-systems-test#parkinsons-disease.
- ↑ Dynamic Gait Index. Shirley Ryan AbilityLab. 2022 [cited 10 May 2022]. Available from: https://www.sralab.org/rehabilitation-measures/dynamic-gait-index
- ↑ Bereczki D. The description of all four cardinal signs of Parkinson's disease in a Hungarian medical text published in 1690. Parkinsonism & related disorders. 2010 May 1;16(4):290-3. DOI: https://doi.org/10.1016/j.parkreldis.2009.11.006
- ↑ 21.0 21.1 21.2 21.3 21.4 Giladi N, Manor Y, Hilel A, Gurevich T. Interdisciplinary Teamwork for the Treatment of People with Parkinson’s Disease and Their Families. Curr Neurol Neurosci Rep. 2014 Sep 23;14(11):493. DOI: https://doi.org/10.1007/s11910-014-0493-1