Parkinson's Disease: A Case Study

Abstract

This fictional case study is a 68 year old retired farmer (female) who has been diagnosed with early stage idiopathic Parkinson's Disease and received a referral for physiotherapy. The case study documents her intake assessment until 12 weeks follow up and a summary of the major outcomes.

Introduction

Parkinson’s Disease (PD) is a progressive neurodegenerative disease which is a result of compromised nerve cells in the basal ganglia. The disease is characterized by a loss of motor function in addition to non-motor symptoms such as difficulty with memory and thinking [1]. Some of the characteristic symptoms of this disease include resting tremor, bradykinesia, hypertonicity, slowed voluntary movements, and postural instability [1].

In this case study, Gail Brown, a 68 year old female, has been diagnosed with PD and is experiencing symptoms associated with the preliminary stages of the disease, such as resting tremor and balance issues. Though this condition has a higher prevalence rate in males [1], it should be noted that there is significant under-representation of females in the literature and research surrounding PD. Females may have a different presentation of symptoms as compared to males, and a lack of research in regards to this has been linked to poorer outcomes for females with this disease [2].

Literature shows that physical activity and treatments such as Nordic walking [3], dance [4][5], and musical cueing [6] are effective in minimizing and delaying progression of symptoms in patients with PD. Physical activity, and specifically resistance training, is also effective in reducing the non-motor symptoms of PD, such as depression [7].

There is a high prevalence of depression in patients with PD, occurring in almost half of all patients with female gender being an additional risk factor [8]. The objective of this case study is to highlight Mrs. Brown's journey with this disease over the course of 12 weeks through a physiotherapy lens.

Client Characteristics

Gail Brown is a 68 year old female. She is a retired farmer who lives at home alone with her dog. Mrs. Brown's husband passed away 5 years ago. She experienced a minor fall (~3 months ago) after tripping over her dog and landed on an outstretched right hand, leading to wrist pain. She saw her family doctor regarding her wrist, but also complained of some recent trouble with balance and a small hand tremor. She was referred to a neurologist and diagnosed with early stage idiopathic Parkinson’s Disease. She received a referral for physiotherapy to perform a falls risk assessment, maintain her functional status, and address her concerns regarding the condition.

Examination Findings

The patient had their intake assessment on May 9th, 2020.

Subjective

  • Patient Profile (PP): 68 y/o female
  • History of Present Illness (HPI): Diagnosis of idiopathic Parkinson’s Disease 1 month ago, left hand tremor (~5 months), right hand dominant and decreased handwriting size (~5 months), decreased balance (~1 year)
  • Past Medical History: Right wrist injury (~3 months ago, resolved), Depression
  • Medications: Currently none, received prescription and education for Levadopa (doesn’t feel she needs it yet), Advil for headaches when needed
  • Health Habits: Non-smoker, no longer drinks alcohol (~3 years)
  • Psychosocial: Patient describes feeling lonely, isolated, and frustrated with diagnosis. Showing signs of depression. She has avoided going to see her friend due to feeling unsteady, and fear of falling (~3 months). Daughter lives ~2 hours away, and visits 1-2 times/month.
  • Home: Bungalow, lives with dog, 4 stairs into house with railing,10 stairs to basement with railing (laundry). Bathroom has large shower/bathtub with non-slip mat but no railing.
  • Previous Functional Status:
    • Prior to onset of PD symptoms (decreased balance and tremor): able to walk about ~200m to her friends house, gardening, performed ADLs independently, driving often (grocery store, recreation centre)
    • Prior to husband passing (~5 years ago): attended dance classes, was very active with farm work
  • Current Functional Status
    • Since onset of PD symptoms: Drives when necessary but less confident with reaction time, less confident walking outside, no issues with dressing/bathing, no problems with stairs, no problems with bed mobility
  • Imaging: MRI scheduled for next week to rule out other causes of symptoms.
  • Precautions/Contraindications: Depression, lack of social support, right wrist injury (~3 months ago)

Objective

  • General: Slight masked face, slight muscular deconditioning, mild dysarthria, mild left resting hand tremor which increased while discussing history of diagnosis
  • Posture: Moderate kyphotic forward head posture
  • Gait: Mild bradykinesia

AROM:

  • U/E: Limited bilateral shoulder flexion and abduction L>R
  • Trunk: Limited in bilateral rotation
  • L/E: Limited in bilateral hip extension, bilateral dorsiflexion (non-WB) L>R
  • All other ROM WNL

PROM:

  • U/E: Limited bilateral shoulder flexion and abduction L>R
  • L/E: limited in bilateral dorsiflexion (non-WB) L>R
  • All other ROM WNL

**Some limits due to mild rigidity (cogwheel)

Strength:

  • Grip strength: L hand 20kg, R hand 18kg
  • Overall strength: L 4/5, R 4+/5
    • Apparent weakness in antigravity muscles (back and neck extensors, hip extensors, quads, hip flexors)

Sensation: U/E and L/E intact

Neurological testing (myotomes, dermatomes, UMN tests, reflexes): normal

Tone: normal

Self-Reported Outcome Measures:

Outcome Measures:

  • Timed Up and Go (TUG): 13.2 seconds
    • With cognitive task (counting backwards from 100 by 3): 13.7 seconds
    • With dual motor task (carrying glass of water in R hand): 15 seconds
  • Berg Balance Scale (BBS): 40/56
    • Most affected areas: tandem stance, turning 360 degrees, standing with feet together, standing with eyes closed

Clinical Impression

The patient is a 68 y/o female with idiopathic early stage PD. Her subjective interview indicated that she is independent in her ADLs, but she is concerned regarding her balance and ability to participate in some activities. She also has a history of depression. Major clinical findings from the objective assessment revealed mild bradykinesia, mild deconditioning, decreased right hand strength (could be reflective of recent wrist injury), resting tremor in left hand, kyphotic posture, and decreased ROM (shoulders, hips, ankles).

Self report measures revealed a moderate score for depression (PHQ-9 score of 12)[9], and moderate confidence on the ABC scale[10]. She demonstrated only mild impairments due to PD on the PDQ-39 scale[11], and areas with the lowest scores were mobility, emotional well being, and social support. These findings indicate that her lack of confidence and depressive symptoms may be leading to decreased participation in activities. There were no indicators of impaired cognition during the assessment and based on her responses to the PDQ-39.

This patient may be at an increased risk of falls due to decreased strength of anti-gravity muscles, and relevant outcome measures. Her TUG score was 13.2s (above cut score for PD of 12s), and TUG with dual motor task score was 15s (above cut score for PD of 13.2s)[12][13]. A BBS score <45 points indicates risk of falling [14], and this patient scored 40 points. These findings indicate the need to include balance and gait components in her treatment plan.

Mrs. Brown, who received a recent diagnosis of PD is otherwise generally healthy and attempting to remain active, however this has been limited over the past few months by her fear of falling and recent onset of depressive symptoms. She is a good candidate for physiotherapy treatment, with involvement of other healthcare professionals.

Problem List

  1. Depressive symptoms
  2. Fall risk and decreased confidence
  3. Resting tremor L hand
  4. Mild bradykinesia
  5. Kyphotic posture
  6. Decreased balance
  7. Muscle deconditioning
  8. Mild dysarthria
  9. Decreased ROM

Intervention

Patient Goals

  • Short Term Goals: Within 4 weeks Gail will...
    1. Improve ABC score from 65% to 75%.
    2. Walk to friend's house (200m one way) using Nordic walking poles.
    3. Attend dance program at the recreation center 2x/week beginning in 2 weeks.
  • Long Term Goals: Within 12 weeks Gail will...
    1. Improve BBS from 40 to 47.
    2. Walk her dog for 30 minutes around the neighborhood.

Treatment Plan

Frequency Intensity Time Rationale
Education
  1. Role of the Physiotherapist (PT)
  2. Energy conservation methods
  3. Environmental modifications
During her initial appointment with check ins as needed As appropriate Ongoing To ensure understanding of the role of PT, the purpose and effectiveness of her program, increasing compliance to her program while promoting her safety.
Gait
  • Nordic walking
  • Musical cueing
4 days/week Light intensity 400m total Problem list (2,4,6)

Training of gait and balance in the early stages of PD is effective in its prevention of falls[15]. Nordic pole walking has been found effective in improving balance, postural control, movement coordination, walking ability, and positively affecting socialization[3]. Musical cueing can improve gait through improvements in speed of gait, and length of stride [16]. These aspects also address Mrs. Brown’s decreased level of confidence.

Balance Training

From BBS:

  1. Tandem stance
  2. Turning 360 degrees
  3. Standing with feet together
  4. Standing with eyes closed

Examples (tandem stance, visual cues, balance boards, single leg stance)

In clinic
  • 1x/week for the first month

At home

  • 1x/week for the first month
  • To progress to be functionally included in her everyday
Working within the limits of her stability 30 minutes
Community Dance Program 2x/week Moderate intensity 1hr Problem list (1, 2, 4)

Participation in dance for patients with PD can lead to improvements in balance and motor impairment helping to decrease the risk of falls, additionally, the socialization aspect of this activity is positive for overall quality of life[4].

Strengthening
  1. General strengthening - Kitchen sink exercises
  2. Grip strength
  3. Postural strengthening/Motor control
3x/week 60% of 1RM 3 sets of 10 Problem list (2, 5, 6, 7)

When gait and balance training are combined with postural motor control learning they are effective in the prevention of falls [15]. As well, lower extremity strengthening can help to improve balance more so than balance training alone, which can further help decrease her risk of falls [17]. Mrs.Brown’s grip strength appears to be a lasting limitation from her fall and strengthening here could ensure that she gains her full functioning in this wrist which can assist in her continued independence and activities.

ROM
  1. Shoulder
  2. Hip
  3. Dorsiflexion
  4. Trunk rotation
3x/week Reach a point where you can feel the stretch but not past the point of pain 20s static stretch x3 sets

OR

60s dynamic stretch

Problem list (2, 9)

Improving Mrs.Brown’s ROM can translate into her gait and balance training and contribute to her continued independence in performing her ADLs [17].

Note:
  • This program was developed to enhance Mrs. Brown's life in these early stages of her PD and reflects her current abilities and functionality as she was previously quite active.
  • The program was reviewed in clinic and progressed as needed throughout treatment.

Inter-professional Health Team

  • Already involved:
    • Family doctor
    • Neurologist
  • To be involved[18][19]:
    • Occupational Therapist: Driving assessment (due to her concerns about reaction time), Home assessment (bathroom specifically)
    • Psychologist: Regarding depressive symptoms
    • Speech Language Pathologist: Regarding dysarthria noted
    • Involvement in a PD support group

Outcome

After the initial assessment it was decided that Mrs. Brown would receive 12 weeks of physiotherapy to address her impairments and implement a home exercise program. She was seen 1x/week for 4 weeks, followed by appointments every 2 weeks for the remaining 8 weeks. At this point she was reassessed before deciding how to proceed with ongoing therapy.

Major outcomes included: improved overall strength (upper body and anti-gravity muscles); ROM improving to 90% of normal; increased grip strength (approaching normal ratio). Her residual impairments include kyphotic posture and mild balance impairments. She has enjoyed using her Nordic poles to get to her friends house, feels confident walking her dog, and has made some new friends at her dance class.

  • Grip strength: L hand 21kg, R hand 20kg
  • ABC: 85%
  • PHQ-9: 5
  • PDQ-39: 20/156 = 13%
  • BBS: 45/56
  • TUG: 9.5s
    • Cognitive = 12s
    • Dual motor task = 12.8s

After 12 weeks of the described treatment plan, Mrs. Brown’s ABC score improved from 65% to 85%. This indicates a true change (MDC of 11-13) and that she is no longer a risk for falls (in PD patients >80% = decreased risk of falls)[10]. Her PHQ-9 score has decreased to 5, which is in the “mild-none” category for depressive symptoms[9]. Her three TUG scores (normal, cognitive task, dual motor task) have all decreased below the threshold for falls risk, and she experienced a true change in her normal TUG score (MDC = 3.5)[13]. On the PDQ-39, her score has improved but does not meet the MDC. There was an improvement in the areas of mobility, emotional well-being, and social support (ie. these have been affecting her life over the past month to a lesser extent)[11]. Her BBS score improved to 45/56 indicating a true change and a decreased risk of falling[14].

She achieved STG #1, STG #2, STG #3, LTG #2. Her BBS score significantly improved but did not meet LTG #1.

Based on Mrs. Brown’s current status after 12 weeks of treatment it was decided that the frequency of her appointments would be reduced. A 1-month follow up appointment was scheduled for continued evaluation and treatment progression. There will also be ongoing communication with the described interprofessional health team.

Discussion

Gail Brown (68 y/o) presented with a diagnosis of early stage idiopathic Parkinson’s Disease. Her initial assessment revealed that she had depressive symptoms, decreased confidence in independent mobility after a fall 3 months prior, but overall moderate strength and range of motion. She was independent in her ADLs, and therefore the treatment plan was aimed at maintaining her function while increasing: confidence, social support, involvement in community activities, strength, balance, and range of motion.

Aspects used in Mrs. Brown’s treatment plan specifically related to her goals and diagnosis of PD are: Nordic walking, musical cueing, and dance. Nordic walking can improve the coordination between the upper and lower body, improving balance and independence related to tasks of ADLs and can positively impact socialization[3]. Musical cueing can increase gait speed and stride length which along with safety while being mobile, addresses many of the issues that PD has on gait [16]. The improvement of balance and motor impairment, as well as the social aspects of dance and their effects on quality of life are some of the many beneficial aspects of the use of dance in patients with PD[4]. Mrs. Brown‘s lower perceived confidence in her balance and a slow TUG time put her at a risk for falling [20]. It was imperative to consider her low self confidence as a risk factor for falls and an issue to be addressed.

After 12 weeks the treatment plan was effective at increasing Mrs. Brown’s outcome measure scores, and her overall well-being. The goal moving forward is maintenance, and to re-evaluate and adjust treatments as new problems arise. Although she is in an early stage of PD, research supports both early intervention and involvement of a multidisciplinary team to facilitate communication between healthcare professionals and the patient[19]. Key members of a movement disorders team in the addition to a physiotherapist could include: speech language therapist, occupational therapist, psychologist, social worker, and a specialized nurse. A speech language therapist should become involved at the onset of communication and or/swallowing difficulties. Occupational therapy is important to promote ADLs and create safer environments (eg. equipment). Finally, psychologist involvement is important for coping strategies, and in this case to address depressive symptoms[19]. A social worker and specialized nurse were not involved in this case however they may also play important roles early on and as the disease progresses.

The involvement of a psychologist early on in Mrs. Brown’s treatment is a crucial aspect of her treatment plan due to her prevalent depressive symptoms[8]. In addition to this referral, the strength training component of Mrs. Brown’s treatment plan has been shown to have a significant impact on the reduction of depressive symptoms in patients with PD, by improving their quality of life as well as functionality[7]. Mrs. Brown’s increased confidence and independence as a result of her treatment plan will allow her to continue with her ADLs and maintain social activities, thereby helping to alleviate her depressive symptoms.

Overall, this case highlights the treatment path for a female in the early stages of Parkinson's Disease. This case attempted to evaluate Mrs. Brown from a broad perspective, taking into account how depression impacts functioning and treatment outcomes [8] [7]. Females may present differently in their symptoms which demonstrates the need for more research on PD specifically in females [2]. As research in this area progresses, it is possible that different treatment techniques may become more relevant to the described patient.

References

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Self-Study Questions Related to Mrs. Brown's Case:

1 - Your Patient with the diagnosis of Parkinson's Disease scored 65% on the ABC scale, and 40/56 on the Berg Balance Scale during your initial assessment. How would you interpret this score?

a) She is at no risk of falling and balance exercises should not be included in the treatment plan

b) She is at a risk of falling and the treatment plan should focus on improving her balance and confidence

c) She is at risk of falling and the treatment plan should focus on improving her ROM 

2 - Which of the following are NOT evidence-based effects of Nordic walking in patients diagnosed with Parkinson's Disease?

a) Improved balance 

b) Improved socialization

c) Decreased resting hand tremor  

d) Improved postural control 

Answers: 1(b), 2(c)