Parkinson’s Case – Case Report

History: Patient was a 69 year old male, who had been given a diagnosis of Parkinson’s disease approximately 4 years ago. He reports his initial symptom was tremors in his right hand, and later noticed some unsteadiness in his walking. He suffered a couple of falls prior to the start of physical therapy, both occurring on the stairs in his home, but sustained no significant injuries. At the time of physical therapy treatment, he was living in a 3 story home, and reported difficulty and unsteadiness with stairs, difficulty getting into and out of the car, making quick turns, or moving sideways around obstacles. He was currently using his prescribed Parkinson’s medication 3x per day, and reports he did not notice significant changes in his movement or balance between doses.

Functional Limitations:

• Unsteadiness on stairs
• Repeated falls
• Difficulty getting into and out of car
• Unsteadiness with tight turns, or turning in place
• Difficulty moving through tight spaces, and side stepping around objects

Objective testing focused on functional mobility for this patient and included:

• Activities Specific Balance Confidence Scale
  • This is a questionnaire in which the patient rates their confidence in performing various tasks without falling. A score of 100% would indicate no concern for falling.
  • Patient’s initial score was 59%
  • Score at Discharge 71%
• Timed Up and Go Test
  • This is a test in which a patient is asked to rise from a chair, walk a short distance, turn around and return to the chair and sit back down. There is a great deal of research suggesting optimal performance time for this test, for healthy adults, and for those with Parkinson’s. For healthy adults, it is suggested that a score greater than 14 seconds suggests increased risk of falling down. For those with Parkinson’s disease there is research to suggest a score greater than 11.5 seconds, or a score greater than 8 seconds can be indicators of higher fall risk
  • Initial score: 12.3 seconds
  • Score at Discharge: 9.7 seconds
• Five Time sit to stand test
  • This is a test in which a patient is asked to sit in a chair with their arms across their chest, and to then rise to standing and return to sitting 5 times in a row, without use of their hands. Research suggests for those within this patient’s age range, an average scores is 11.4 seconds to complete this task
  • Initial score: 34.3 seconds, with patient needing to use his hands on his thighs to assist in the final repetition
  • Score at Discharge: 18.58, with no use of hands
• Self Selected, and fast paced Gait speed
  • These are tests to assess the gait velocity or speed at both a comfortable pace, and when prompted to walk as quickly as the patient is able without running. These values are recorded in meters per second, with a higher score indicating a faster pace.
  • Initial Self Selected gait velocity: .916 m/s
  • Initial fast paced gait velocity: 1.425 m/s
  • Discharge self paced gait velocity: .87
  • Discharge fast paced gait velocity: 1.312
  • While these scores appear to have declined slightly, these minor differences in gait speed from start of care to discharge are not significant enough to suggest any meaningful change for better or worse. Research suggests self paced gait speed must change by greater than .18 m/s to indicate a meaningful change.
• 4 square step test
  • This is a test in which a grid is placed on the floor, and patient is asked to step forward, sideways, and backwards through the grid as directed to bring both feet into each of the 4 boxes of the grid, without contacting the grid lines. For the Parkinson’s population, and specifically those using Parkinson’s medications, research suggest an average score of 9.6 seconds.
  • Initial score 15.88 seconds
  • Discharge score 11.9
• 8 Alternating step taps on 8 inch step
  • Patient was asked to stand in front of an 8 inch step, with arms at his sides, and to tap each foot onto the top of the step, without stepping up. He was instructed to alternate feet, for a total of 8 taps.
  • Initial score 13.14 seconds
  • Discharge score 7.92 seconds

Treatment Plan and Summary: The treatment for this patient included 8 weeks of care, with 2x per week visits, and resulted in the above listed improvements in functional mobility scores. Treatment was focused on exercise based movement retraining, and focused on using large scale motions, and balance exercises. This treatment allowed the patient improved functional strength for every day tasks such as rising from a low chair, feeling steadier on the stairs in his home, and allowing him to feel safer navigating around obstacles in his home and community. Patient was advised to return back to PT in approximately 6 months, to reassess these same mobility measures and determine if the patient’s mobility scores are remaining unchanged, further improving, or declining. If a decline in mobility measures is seen, physical therapy is recommended to boost functional mobility and safety. The patient was provided with his initial scores, re-evaluation measures, and discharge measures on a written chart so that he can easily share these values with his care team, and can easily review changes over time when these measures are repeated in the future.