Parkinson's Case Study - John (Initial Assessment)

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem and Tarina van der Stockt

Client Characteristics

John is a 60 years old man who was diagnosed with Parkinson's five years ago. His treatment program was based on medications and exercises which has helped him in managing well.

John is an active family man who still works, attends a gym for regular exercises and does a lot of community work.

He attended a teaching session, reporting his main problem that he wanted addressed by physiotherapy as pain in his right ankle impacting on his walking.

Examination

Standing

Observing John in a standing position for a length of time, his body weight was shifted to the left away from the side pain. As he continues to stand for longer, the effects of dystonia as the main cause pulling the right leg into an unnatural position where it takes little weight.

''Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures, or both. Dystonic movements are typically patterned, twisting, and may be tremulous''[1]

This interferes with the proprioception feedback resulting in poor joint control, altered soft tissue tension to facilitate the correct alignment and movement from the ground upwards. Even his hands were held over to the left side. Increased tone (dystonia) causes John’s right leg to be drawn inward into adduction, or into flexion (possible reflex responses). This becomes (already is) a problem in terms of balance, and a cause of pain, which John mentions as a main problem affecting his mobility, as he doesn’t place the foot correctly in stand/ walking.

This observation leads us to think about how to enhance the sensory input to John’s right side so the leg is better aligned to take weight correctly, reducing the strain through his ankle.

Sitting

John also demonstrated asymmetry in his sitting posture and lack of awareness of the position over the right side, it kept moving throughout his conversation

TUG

Gait disorders in PD such as FOG can be difficult to measure as it shows high degrees of variability and asymmetry[2]. Several screening measures are used to assess function and gait in PD, such as Berg Balance Scale (BBS), Functional Ambulation Category (FAC), gait speed, Timed “Up & Go” Test (TUG) and the Functional Gait Assessment (FGA)[3].

The Timed up and go test of functional mobility was used to assess John while walking. This is a useful and validated tool[4] to consider risk for fall through upright function and gives us an idea of leg strength/ power to stand (vertical lift without use of arms), balance at initial stand, walk pattern including the turn, and control of the sit through eccentric muscle strength of thighs. All the components of the test are related to aspects of body fitness that might be a risk of falling.

The test showed:

  • No start hesitation (good)
  • Asymmetry in step length, but gait continuity
  • propulsion gained through a pull forward (especially on right stance) through forward flexion, rather than a push forward through extension, with largely flexed posture.
  • Right side specific; arm held in extension at gleno-humeral joint, in flexion at elbow and hand closed (tremor). This is a typical pattern the body uses to help keep a body upright, when it is bent from lower than the waist. The trunk twists backwards on right stance so little pattern of heel contact to set up hip loading and extension for automatic propulsion, yet there was still arm swing generated from the speed of his walk. 

*This page forms part of the Parkinson's Disease Outcome Measures Case Study Course

References:

  1. Albanese A, Bhatia K, Bressman SB, Delong MR, Fahn S, Fung VS, Hallett M, Jankovic J, Jinnah HA, Klein C, Lang AE, Mink JW, Teller JK. Mov Disord. 2013 Jun 15; 28(7):863-73.
  2. Chen PH, Wang RL, Liou DJ, Shaw JS. Gait disorders in Parkinson's disease: assessment and management. International Journal of Gerontology. 2013 Dec 1;7(4):189-93.
  3. Yang Y, Wang Y, Zhou Y, Chen C, Xing D, Wang C. Validity of the Functional Gait Assessment in patients with Parkinson disease: construct, concurrent, and predictive validity. Physical therapy. 2014 Mar 1;94(3):392-400.
  4. Nocera JR, Stegemöller EL, Malaty IA, Okun MS, Marsiske M, Hass CJ, National Parkinson Foundation Quality Improvement Initiative Investigators. Using the Timed Up & Go test in a clinical setting to predict falling in Parkinson's disease. Archives of physical medicine and rehabilitation. 2013 Jul 1;94(7):1300-5.