Parkinson's Case Study - John (Treatment)

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson and Tarina van der Stockt

Read Initial Assessment page first

Clinical Reasoning

Making clinical decisions depends on our knowledge, skills and setting (time, space and equipment available to carry out treatment). In this case study, John's request was a look at the walking.

A large part of the treatment focused on different ways to:

  • Re-orientate John’s left and right side, especially through soft tissue stretches and active movement for sensory reintegration
  • To activate his extensor system thus making John’s movement patterns more natural (automatic), first in lying, then when upright

Gait Re-education

The goal was to enable John to feel the effects of loading weight onto the right leg from hip down to access his extensor system. This initially involved enabling John to feel he had length in the abdominal soft tissue to minimise the pull into flexion (strong pull as John has habituated this use of flexion to drive his forward momentum). To break this pattern and enable propulsion to come from extension the treating physio wanted John to experience a feeling of gaining length to his ventral torso, and active extension of his back muscles.   

At first, the lack of proprioception to allow this, and resulting reduced ability to balance was notable, but by the end, John managed to control his upright position and weight transference onto the right. The lack of extension from the right buttock was very noticeable in the backward stepping, but the steps became larger and were initiated from his buttock muscles, demonstrating better motor control and balance.  

Gait re-education is a form of cognitive training aiming to increase patient's awareness of their body and encourage them to actively correct deviations. Walton et al[1] reported reduced severity of Freezing Of Gait by using Cognitive training measures.  

Post-treatment Assessment

On a visual analogue scale asking John’s pain level from 0 (no pain) – 10 (the most painful he could tolerate), John reported he had no pain in the right ankle post-treatment.

Standing: the treatment session has improved both his sensory (tactile, mechanical pressure and proprioception) and extensor systems, so the brain automatically aligns his body more evenly when he is standing upright. John’s weight became far more evenly distributed through feet, which are both flat on the ground, and arms now more centrally held.

TUG test: the first part is of the first walks of the Timed up and go gives us a baseline measure of time and performance; then stepping backwards; and finally the motor-on-motor aspect of Timed up and go, with John clapping over each shoulder. Post-session was an overall gain in extension, leading and weight bearing on right and better movement quality, a faster walk and better step symmetry.

The improved step length and upright stance meant that his walk was faster, but even better than that was the fact that on the pre-treatment tests, adding the clap for the motor-on-motor test, plus the calling out of names for the cognitive-on-motor test all demonstrated interference, so John was more that 10% slower by adding the dual task into the walk. This was not the case in post treatment assessment so John’s walk was safer and more automatic with the clapping.

Evidence shows similar results to John's case study. A study investigated the effect of a rehabilitation program on balance and gait and found improvements in tandam balance, time, number of steps and average step length in the 10 m walk test[2].

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

References:

  1. Walton CC, Mowszowski L, Gilat M, Hall JM, O’Callaghan C, Muller AJ, Georgiades M, Szeto JY, Martens KA, Shine JM, Naismith SL. Cognitive training for freezing of gait in Parkinson’s disease: a randomized controlled trial. npj Parkinson's. 2018 May 18;4(1):15.
  2. Stożek J, Rudzińska M, Pustułka-Piwnik U, Szczudlik A. The effect of the rehabilitation program on balance, gait, physical performance and trunk rotation in Parkinson’s disease. Aging clinical and experimental research. 2016 Dec 1;28(6):1169-77.