Parkinson’s Management: Management of a Patient to Rekindle Interest in Activity - Case Presentation of Maureen

Original Editor - Merinda Rodseth based on the course by Bhanu Ramaswamy

Top Contributors - Merinda Rodseth, Kim Jackson, Tarina van der Stockt and Lucinda hampton  

Background

Maureen is an 82-year woman who has been attending physiotherapy since late 2015. She is a retired Youth Club leader, and lives with her husband in a house. They do all activities together, including holidaying abroad in the Canary Islands for extended periods, and leading a full social life independently visiting friends and family when in the UK.

In terms of activity, Maureen walks regularly, used to swim and attend a line dancing class as well as play bowls – these activities have all been stopped for nearly a year due to the COVID-19 restrictions placed on communities and vulnerable older people.

Apart from a diagnosis of Parkinson’s in 2015, Maureen has arthritic changes to her right knee and left hip and asthma. She has a longstanding leg length discrepancy (noted in her youth as right leg longer than left) and susceptibility to a kyphotic posture.

Maureen’s goal has always been to remain as fit and well as she can, given her advanced age, her Parkinson’s and her postural changes.

The assessments over time have been to monitor fitness components and included:

1. The Tragus-to-wall test to review ability to alter posture from her default position
2. Strength testing of the lower body with the 5 times sit-to-stand test
3. Balance with the four step balance test, plus specific to the PD Warrior programme, also did the MiniBEST test.
4. Gait using the Tinetti gait score (version 7), forwards/backwards walking
5. Timed up and go tests for added understanding of functional changes when altering position whilst moving.

Manual treatments focussed on regaining Maureen’s flexibility and postural alignment, plus introduced exercise programmes to keep her fit (including the PD Warrior programme).

Overall, Maureen has done well, progressing to improve her fitness levels over the first two years during consultations, then plateauing. A dramatic change was noted in 2020 when Maureen’s activity had to cease due to the COVID-19 restrictions, leaving her stiffer and de-conditioned.

Current Presentation

On her return to the clinic, Maureen requested a review of her respiratory condition (she was increasingly wheezy) and her fitness levels, as she was also increasingly more out of breath with any activity.

During the assessment Dr Bhanu Ramaswamy focused on Maureen’s gait, observing her forwards and backwards walking. The forwards and backwards walking test, whilst easy to do, has little quantitative information to record apart from the number of steps it takes to complete the test over the distance. This supports the proposition that the importance of gait analysis lies in its application - as a means to diagnose pathology as well as establish and evaluate a treatment plan. Gait dysfunction is also useful for assessing risk of falling and quality of life (QoL) in individuals with Parkinson’s. Forward and backward walking is especially useful for assessment in Parkinson’s. Backward walking is often more impaired in individuals with Parkinson’s and can identify elderly fallers more accurately than forward walking.

Various parameters exist for the evaluation and quantitative interpretation of gait. Individual gait parameters (stride length, speed) does however not take into account the full complexity of the mechanics of gait, and whilst good to note, should not be the only factors assessed during gait. Instrumented gait analysis as performed in a gait analysis lab, can provide thorough and measurable information, but is often not available for clinicians in a clinical setting. Gait analysis is therefore mostly conducted through clinical observation. Observation also allows assessing the quality of the gait - how the patient walks - which is useful for informing the treatment plan of the physiotherapist. While assessing gait, it is useful to keep the following factors in mind:

• Speed of walking/walking velocity (distance over time - for e.g. meters/second)
• Cadence (number of steps per minute)
• Stride/step length
• Step width
• Floor clearance
• Posture/biomechanics of the body as well as variability, asymmetry and postural control.

Resources

• Instrumented gait analysis
• Functional Gait Assessment
• Hackney ME, Earhart GM. Backward walking in Parkinson's disease. Movement disorders: official journal of the Movement Disorder Society. 2009 Jan 30;24(2):218-23.
• Gilmore G, Gouelle A, Adamson MB, Pieterman M, Jog M. Forward and backward walking in Parkinson disease: a factor analysis. Gait & posture. 2019 Oct 1;74:14-9.