The Effect of Rhythmic Auditory Stimulation on a 75 year old male with Parkinson's Disease- A Case Study

Original Editor - Thomas Kerr Top Contributors - Steven Mylonas, Thomas Kerr, Yuho Choi, Frank Huang and Daniel Asch
Top Contributors - Thomas Kerr, Yuho Choi, Steven Mylonas, Frank Huang, Dan Asch

Abstract

The purpose of this case study is to investigate the efficacy of Rhythmic Auditory Stimulation (RAS) as a treatment for gait abnormalities in older age adults with Parkinson’s Disease (PD). The case study is focused around a client who has mild to moderate PD symptoms who seeks physiotherapy to increase his gait speed, walking distance and overall independence for his basic activities of daily living (ADLs). RAS is a treatment technique for PD patients, which is designed to improve gait by providing the patient with auditory cues throughout gait[1]. This intervention was implemented 4 days per week (Monday, Tuesday, Thursday & Friday) for a total of 8 weeks; these gait training sessions were 30 minutes in length and were embedded within 90-minute rehabilitation sessions. The physiotherapy treatment plan was developed after consulting with the patient to create goals and assessing his function using a variety of validated outcome measures, such as the Unified Parkinson’s Disease Rating Scale (UPDRS), Timed Up and Go Test (TUG), Berg Balance Scale (BBS) and Mini Balance Evaluation Systems Test (Mini-BEST). After the 8-week intervention, the patient experienced mild improvements in gait and balance; he improved from 42 to 45 on the BBS, from 19 to 23 on the Mini-BEST, from 18 to 15.5 seconds on the TUG, and from 39 to 34 on the UPDRS Part III. Although these improvements are not statistically significant, they are changes that we would expect to see within an 8-week rehabilitation program. These outcomes are meaningful in the sense that we were able to see progress in the right direction with this PD patient.

Introduction

Mr. Brown is a 75-year-old man who was diagnosed with PD, a progressive neurodegenerative disease of the central nervous system (CNS) affecting both motor and cognitive systems[2][3]. Specifically, PD is a disorder which is characterized by the loss of dopaminergic neurons in the substantia nigra and basal ganglia consequently diminishing motor function and causing non-motor symptoms[4]. Typical symptoms include bradykinesia, akinesia such as freezing, rigidity, resting tremor, postural instability, decreased dexterity and masked facial expression[5]. Other symptoms may include mild cognitive impairment and potentially more extreme impairments such as dementia[2][3]. The objective of this case study is to demonstrate the efficacy of RAS as a treatment for bradykinesia and decreased gait speed in patients with PD. Similar cases that would be relevant to this case study would include PD in older-aged adults who want or need to improve balance, gait pattern and gait speed.

Client Characteristics

Mr. Brown is a 75-year-old man who was diagnosed with Parkinson’s Disease 5 years ago, with a recent worsening of symptoms. He has been on Levadopa for the past 2 years and presents with bradykinesia, rigidity and resting tremor in his left upper extremity. Upon examination of gait, Mr. Brown demonstrates reduced speed and amplitude of movement and requires the use of a cane during winter months. Mr. Brown currently lives alone on the first floor of a condominium in Toronto, Ontario, Canada, and is independent with his ADLs, but complains that it takes him a long time to complete few tasks throughout the day. His primary reason for seeking help from physiotherapy is to increase his gait speed, walking distance and improve gait pattern so that he is better equipped to complete his ADLs as he ages.

Examination Findings

Subjective Assessment:

Mr. Brown is a retired University of Toronto Chemistry professor who lives alone on the first floor of a condominium. He is currently independent with all ADLs, however, activities take him a long time to complete. He has a grandson who lives nearby to help him with any tasks he needs. Mr. Brown enjoys meeting friends for coffee, however, he explains he has recently stopped attending because it takes him way too long to walk to the coffee shop. The patient reports that he feels slightly unstable while walking, and becomes very frustrated with his slow walking speed.

History of Present Illness:

  • Medical Diagnosis (Dx): Parkinson's disease
  • Rehabilitation History: Spent 1 year attending physiotherapy after diagnosis. Symptoms improved, however, his condition has slowly declined since.
  • Current Symptoms: feeling unsteady, fatigue, slow-moving, difficulty with gait.

Previous Medical History:

  • Past Medical History: Fracture of right arm when he was 22, GERD, THA 12 years ago, previous history falls.
  • Family Medical History: Coronary artery disease (CAD)

Medications:

  • Famotidine
  • Carbidopa-levodopa

Objective Assessment:

General Observation:

  • Posture - Forward leaning posture, slouched internally rotated shoulders, exaggerated kyphosis in the thoracic spine with head forward
  • Tremor - Tremor on left upper limb at rest with fine pill rolling characteristic
  • Other - Slight masked facial expression

Active Movements: Mr. Brown demonstrated evidence of bradykinesia throughout active ranges of motion (AROM) across several joints in the upper and lower extremities. His AROM included the following:

  • Trunk rotation limited to 85% bilaterally
  • Head rotation limited to 80% bilaterally
  • Shoulder flexion (arms above head) limited to 85% on left side
  • Shoulder abduction (arms out to the side) normal
  • Shoulder extension (behind back) limited to 75% on left side

Muscle Tone / Passive Range: Mr. Brown demonstrated moderately increased bilateral tone and rigidity in his quadriceps and biceps when tested at various velocities. Additionally, he demonstrated moderate rigidity in his left arm/hand, with a cogwheeling pattern that would constantly catch and release.

Voluntary Movements: Mr. Brown’s performance of rapidly alternating movements of his upper and lower limbs were also evaluated. When asked to bring his finger to his nose repeatedly, he demonstrated diminished amplitude over time, as well as more irregular temporal and spatial performance of the task. Repetitive closing of the hands, finger tapping, and foot tapping were performed at a reduced amplitude and velocity with worsening progression after a few repetitions. These movements indicate fatigable weakness in the hands and feet.

Balance: The patient experienced backward postural instability, which was primarily noticed after performing standing balance tasks within the Berg Balance Scale. The following were Mr. Brown’s balance scores:

  • Berg Balance Scale total score: 42/56 (indicates an increased risk of falls)
  • Mini-BEST total score: 19/32 (test scores represents an adequate ability to identify fallers)

Functional Mobility / Gait: Mr. Brown experiences moderate irregularities in his gait, such as decreased step length bilaterally, decreased speed and decreased arm swing (particularly on the left side). He also exhibits festination and has akinesia (freezing) that gets worse when turning towards the left. His TUG score was 18 seconds on initial assessment (indicates an increased risk of falls).

Other Outcome Measures:

  • Modified Hoehn and Yahr Scale: Mr. Brown is at stage 3 of the Modified Hoehn and Yahr Scale, which indicates that he has “mild to moderate involvement; some postural stability but physically independent; needs assistance to recover from the pull test.”
  • UPDRS Part III: Motor Examination: Mr. Brown last took Levadopa 2 hours before the physiotherapy assessment. Thus, the patient’s clinical state was marked as “ON,” as he was at his typical functional state when receiving medication, and he has a good response from Levadopa. Dyskinesia was not present during the exam, and as such, did not interfere with the rating. Mr. Brown scored a 39/84 on Part III of the UPDRS.

Clinical Impression

Physiotherapy Diagnosis: Mr. Brown is a 75-year-old male who presents with impaired motor function and coordination, with resting tremor and rigidity that mostly affects the left non-dominant side. He presents with a slow and irregular gait pattern but has independent functional mobility and activities of daily living.

Problem list:

  • Trouble completing ADLs
  • Resting tremor
  • Freezing (akinesia)
  • Muscle rigidity - primarily noticeable in the upper left extremity
  • Forward posture and exaggerated kyphosis
  • Decreased balance
  • Bradykinesia - general slowness of movement
  • Slow gait with reduced step length and decreased arm swing

Intervention

Patient Treatment Goals:

Short Term Goals (STG):

  • Mr. Brown would like to begin making some improvements in his walking speed so that he is at least able to score 16.5 seconds on the TUG by 4 weeks of interventions.
  • He would also like to improve his understanding of PD and implement strategies he can use to improve fatigue levels by 4 weeks of physiotherapy treatment.
  • In the short term, Mr. Brown would like to achieve a 44/56 on the BBS by 4 weeks of physiotherapy treatment.

Long Term Goals (LTG):

  • Mr. Brown would like to improve his balance and stability enough to achieve a 48/56 on the BBS by week 8 of his physiotherapy interventions.
  • Mr. Brown would like to improve his gait speed so that he is able to return to meet his friends for coffee. We have determined achieving 14.5 seconds on the TUG test would be enough return to this activity. He would like to achieve this by 8 weeks.
  • Mr. Brown would like to improve his independence and capacity to perform his basic activities of daily living. In doing so, Mr. Brown must improve his gait speed and his ability to navigate his surrounding environments.


It has been identified in numerous studies that Rhythmic Auditory Stimulation (RAS) is a viable gait therapy technique in patients with Parkinson’s Disease[6][7][8]. In a study by Thaut et al. (1996)[6], patients with PD who trained with RAS over 3 weeks showed a significant improvement in gait velocity and step cadence. RAS is believed to use several auditory-motor pathways that respond to rhythmic time information to stabilize motor control, which in turn enhance gait performance in Parkinson patients[7]. Additionally, training with RAS over 8 weeks is shown to improve balance[8] and reduce freezing of gait in patients with PD[9]. Alongside training with RAS, other treatments include hydrotherapy, which has shown to have a positive effect on UPDRS part III[10], as well as assisted active range of motion (AAROM) for maintaining mobility, and general strengthening using the American College of Sports Medicine (ACSM) endurance training guidelines to maintain muscles mass and strength.

Implementing RAS into an 8-week rehabilitation program for patients with Parkinson's Disease.

Outcome

Mr. Brown’s BBS total score improved from 42/56 to 45/56, which indicates that he is experienced a slight improvement in balance[11]. His Mini-BEST score improved from 19/32 to 23/32, which once again demonstrates a small improvement in his balance[12]. The TUG test time improved from 18 to 15.5 seconds, indicating that he may have a slightly lower fall risk compared to the initial assessment[13], and the UPDRS Part III score decreased from 39/84 to 34/84, indicating a slight improvement in the motor aspects of his symptoms[14]. Note: The above changes are not statistically significant or represent a minimal detectable change, but we would not expect to see drastic changes within the initial 8 weeks of a rehabilitation program. Additionally, Mr. Brown’s progression in rehabilitation is heading in the right direction, especially considering his age and the fact that Parkinson’s Disease is a progressive neurological disorder. After Mr. Brown’s 8-week intervention, a referral was made for outpatient community-based physiotherapy, where he can continue to seek rehabilitation.

Discussion

Applying the rhythmic auditory physiotherapy intervention has helped the patient, Mr. Brown, to reduce the functional regression as a result of Parkinson’s Disease. Although the 8-week protocol did not allow Mr. Brown to regain his full independence, it did provide a small positive impact on his overall quality of life as measured by our selected outcome measures. These improvements did not show statistically significant, but did demonstrate a positive correlation between rhythmic auditory physiotherapy and exercise interventions on gait speed and pattern[15]. This case study has clinical implications for Parkinson populations and as well as their corresponding health care providers who are looking to improve patient gait and functional independence. This case provides examples of the assessment, outcome measures and treatments used for what was designed to be a typical case of mild-moderate Parkinson’s in a senior male. While this case study is not designed to be prescriptive, it offers several suggestions and guidance for physiotherapy interventions for a Parkinson’s patient seeking to improve gait.

Self-Study Questions

A) Which of the following are not evidence-based interventions for patients with Parkinson’s Disease?

  1. Constraint induced movement therapy
  2. Dance
  3. LSVT- BIG
  4. Rhythmic auditory stimulation

B) Which of the following Parkinson’s Disease terms are correct?

  1. Hypokinesia: diminished speed of movement
  2. Bradykinesia: diminished amplitude of movement
  3. Festination: small shuffling steps
  4. Akinesia: Reduced sway during movement

Resources

  1. Auditory Rhythmic Stimulation for Gait Training
  2. Bigger Movements - Better Quality of Life: Parkinson's Disease Case Study
  3. Parkinson's and Dance
  4. Parkinson's Disease

References

  1. Lim I, Wegen E van, de Goede C, Deutekom M, Nieuwboer A, Willems A, et al. Effects of external rhythmical cueing on gait in patients with Parkinson’s disease: a systematic review. Clinical Rehabilitation; London. 2005 Oct;19(7):695–713.
  2. 2.0 2.1 Demaagd, G. & Philip, A. Parkinson’s Disease and Its Management Part 1: Disease Entity, Risk Factors, Pathophysiology, Clinical Presentation, and Diagnosis. Pharmacy & Therapeutics, 2015: 40(8): 504-510, 532.
  3. 3.0 3.1 Gage, H, Storey, L. Rehabilitation for Parkinson's disease: a systematic review of available evidence. Clin Rehabil 2004;18:463-482.
  4. Feigin, A, Eidelberg, D: Parkinson’s Disease – Diagnosis and Clinical Management. New York: Medical Publishing; 2002
  5. Parkinson’s disease - Diagnosis and treatment - Mayo Clinic [Internet]. [cited 2019 May 7]. Available from: https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062
  6. 6.0 6.1 Thaut, M.H., McIntosh, G.C., Rice, R.R.,Miller, R.A., Rathbun, J. & Brault, J.M.(1996) Rhythmic auditory stimulation in gait training for Parkinson's disease patients. Mov. Disord., 11, 193–200.
  7. 7.0 7.1 Thaut, Michael & Abiru, Mutsumi. (2010). Rhythmic Auditory Stimulation in Rehabilitation of Movement Disorders: A Review Of Current Research. Music Perception - MUSIC PERCEPT. 27. 263-269. 10.1525/mp.2010.27.4.263.
  8. 8.0 8.1 Kadivar, Zahra & Corcos, Daniel & Foto, James & Hondzinski, Jan. (2011). Effect of Step Training and Rhythmic Auditory Stimulation on Functional Performance in Parkinson Patients. Neurorehabilitation and neural repair. 25. 626-35. 
  9. Arias P, Cudeiro J (2010) Effect of Rhythmic Auditory Stimulation on Gait in Parkinsonian Patients with and without Freezing of Gait. PLOS ONE 5(3): e9675.https://doi.org/10.1371/journal.pone.0009675
  10. Volpe, D., Giantin, M., Maestri, R., Frazzitta, G. (2014). Comparing the effects of hydrotheraspy and land-based therapy on balance in patients with Parkinson's disease: a randomized controlled pilot study. Sage journal. 28 (12)1210-1217.
  11. Qutubuddin, Abu & O Pegg, Phillip & Cifu, David & Hayes, Rashelle & Mcnamee, Shane & Carne, William. (2005). Validating the Berg Balance Scale for patients with Parkinson's disease: A key to rehabilitation evaluation. Archives of physical medicine and rehabilitation. 86. 789-92. 10.1016/j.apmr.2004.11.005.
  12. Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest, BESTest, and BESTest sections for balance assessments in individuals with Parkinson disease. J Neurol Phys Ther. 2011 Jun;35(2):90–7.
  13. Shumway-Cook A, Brauer S, Woollacott M. Predicting the Probability for Falls in Community-Dwelling Older Adults Using the Timed Up & Go Test. Phys Ther. 2000 Sep 1;80(9):896–903.
  14. Schrag A, Sampaio C, Counsell N, Poewe W. Minimal clinically important change on the unified Parkinson’s disease rating scale. Movement Disorders. 2006;21(8):1200–7.
  15. Forced, Not Voluntary, Exercise Improves Motor Function in Parkinson’s Disease Patients - Angela L. Ridgel, Jerrold L. Vitek, Jay L. Alberts, 2009 [Internet]. [cited 2019 May 5]. Available from: https://journals.sagepub.com/doi/10.1177/1545968308328726