This is a case study of parkinson's disease with complete physiotherapeutic assessment and management

1. By SIMRAN Shaw
CASE PRESENTATION
S
I
M
R
A
N
S
H
A
W

2. Name
DEMOGRAPHIC DATA
Age
Sex
Occupation
GB
68
Female
Retired farmer
S
I
M
R
A
N
S
H
A
W

3. CHEIF COMPLAIN
She complains of trouble with balance
and mild tremor in hand .
S
I
M
R
A
N
S
H
A
W

4. SUBJECTIVE
ASSESSMENT
S
I
M
R
A
N
S
H
A
W

5. HISTORY OF PRESENT ILLNESS
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 and also complained
about the balance issues and tremor in her hand.
She was referred to neurologist and was diagnosed with early stage
Idiopathic Parkinson's disease 1 month ago.
She was then referred to a physiotherapist to address her concerns
regarding the condition.
S
I
M
R
A
N
S
H
A
W

6. She has balance issues since 1 year.
She has left-hand tremor since 5 months (right hand dominant).
She has decreased handwriting size since 5 months.
HISTORY OF PRESENT ILLNESS
S
I
M
R
A
N
S
H
A
W

7. P A G E 0 8
PAST MEDICAL HISTORY
Suffering from Depression
Right wrist injury - Resolved.
S
I
M
R
A
N
S
H
A
W

8. Currently None.
Received prescription and education for
Levadopa - doesn’t feel she needs it yet.
Advil (Ibuprofen)- for headaches when
needed.
DRUG HISTORY
S
I
M
R
A
N
S
H
A
W

9. Non Smoker
No longer drinks alcohol since
3 years.
PERSONAL HISTORY
S
I
M
R
A
N
S
H
A
W

10. PSYCHOSOCIAL STATUS
She describes feeling lonely, isolated and frustrated
with the diagnosis.
Showing signs of depression.
She has avoided going to see her friend due to feeling
unsteady and fear of falling(~3 months).
The daughter lives ~2 hours away, and visits 1-2
times/month.
Mrs. GB's husband passed away 5 years ago.
S
I
M
R
A
N
S
H
A
W

11. ENVIRONMENTAL HISTORY
She lives in a bunglow alone with her dog.
There are 4 stairs into the house with railing.
10 stairs to the basement with railing (laundry).
The bathroom has a large shower/bathtub with a non-
slip mat but no railing.
S
I
M
R
A
N
S
H
A
W

12. FUNCTIONAL STATUS
PREVIOUS FUNCTIONAL STATUS
Prior to the onset of PD symptoms (decreased balance and tremor): able to walk
about ~200m to her friend's house, gardening, performed activities of daily
living(ADLs) independently, driving often (grocery store, recreation center)
CURRENT FUNCTIONAL STATUS
Since the 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
S
I
M
R
A
N
S
H
A
W

13. OBJECTIVE
ASSESSMENT
S
I
M
R
A
N
S
H
A
W

14. Slight masked face
Slight muscular deconditioning
Mild dysarthria
Mild left resting hand tremor
which increased while discussing
history of diagnosis
OBSERVATION
S
I
M
R
A
N
S
H
A
W

15. SENSORY EXAMINATION
U/E and L/E intact
REFLEXES
Normal
ORIENTATION, MEMORY, BEHAVIOUR
Depressed
S
I
M
R
A
N
S
H
A
W

16. TONE
Normal
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-
Weight Bearing(WB)) L>R
All other ROM within normal limit (WNL)
ACTIVE RANGE OF MOTION
S
I
M
R
A
N
S
H
A
W

17. U/E: Limited bilateral shoulder flexion and abduction
L>R
L/E: limited in bilateral dorsiflexion (non-WB) L>R
All other ROM is WNL
**Some limits due to mild rigidity (cogwheel)
PASSIVE RANGE OF MOTION
S
I
M
R
A
N
S
H
A
W

18. MANUAL MUSCLE TESTING
20 kg
18 kg
Overall strength: L 4/5, R 4+/5
Apparent weakness in antigravity muscles (back and
neck extensors, hip extensors, quads, hip flexors)
GRIP STRENGTH TESTING
LEFT HAND
RIGHT HAND
S
I
M
R
A
N
S
H
A
W

19. POSTURE & GAIT ASSESSMENT
POSTURE
Moderate kyphosis
Forward head posture
GAIT
Mild Bradykinesia
S
I
M
R
A
N
S
H
A
W

20. BALANCE ASSESSMENT
Activities-Specific Balance Confidence Scale(ABC Scale): 65%
Timed Up and Go (TUG) : 13.2 seconds
Berg Balance Scale (BBS): 40/56
With cognitive task (counting backward from 100 by 3): 13.7 seconds
With dual-motor task (carrying a glass of water in R hand): 15 seconds
Most affected areas: tandem stance, turning 360 degrees, standing with
feet together, standing with eyes closed.
S
I
M
R
A
N
S
H
A
W

22. SELF REPORTED OUTCOME MEASURES
Patient Health Questionnaire (PHQ-9): 12
Parkinson's Disease Questionnaire (PDQ-39): 38/156 = 24%
Most affected areas: mobility, emotional well-being, social
support
S
I
M
R
A
N
S
H
A
W

23. PDQ-39

25. INVESTIGATIONS
MRI scheduled for next week to rule out
other causes of symptoms.

26. S
I
M
R
A
N
S
H
A
W
DIFFERENTIAL DIAGNOSIS
Idiopathic Parkinson's Disease as diagnosed
Secondary Parkinsonism
Cerebellar dysfunction
Progressive supranuclear palsy
Dementia with lewy bodies
Corticobasal syndrome
Multiple System Atrophy
Punch drunk syndrome

27. PROBLEM LIST
S
I
M
R
A
N
S
H
A
W
Balance - increased fall risk
Gait
Tremor
Depression
Micrographia
Dysarthria
Bradykinesia
Kyphotic forward head posture
Limited ROM in shoulder, hip, trunk , ankle
Mild rigidity

28. PHYSIOTHERAPEUTIC
MANAGEMENT
S
I
M
R
A
N
S
H
A
W

29. FOR RIGIDITY
Generalised relaxation techniques - Jacobson's technique of
progressive relaxation
Gentle Rocking with the use of adult vestibular ball, rocking chair,
and cradle.
PNF - Rhythmic initiation for upper limb and lower limb
Deep breathing exercise
Meditation technique or cognitive imaging
Home Program(H.P) - Relaxation audiotapes

32. FOR MUSCULOSKELETAL FLEXIBILITY
Active ROM exercises or external heating modality
Passive Stretching of shoulder flexors, abductors, hip
extensors, hip abductors & ankle dorsiflexors.
PNF diagonal patterns of upper limb and lower limb
AROM + PROM + PNF :- 5-7 days/week ( min 2-3 days/week)
Pnf technique - Hold relax, Contract Relax
Prolonged stretching for shortened muscles - 4 reps per stretch
held for 50 to 60 seconds
H.P - Encourage self stretching

33. FOR POSTURE
Postural awareness
Extension Exercises
Positional stretching - 20 to 30
minutes
Postural mirror
Patient should try and stretch out his
whole body.
patient should be instructed to lie
supine with a pillow under the upper
thorax.

34. FOR TREMOR
Reducing anxiety helps in
decreasing the tremor.
Relaxation techniques helps.
Yoga
Meditation
For severe tremor - use gloves in
hands or tie any weight in hand.

35. FOR BALANCE
Appropriate verbal, tactile or
proprioceptive cues
By wobble board
By swiss ball
Perturbations while sitting on edge of cot
weight shifts, alternate unilateral
weight-bearing
Reaching out, axial rotation of head and
trunk
Sit to stand

36. FOR BALANCE
Sitting on therapy ball, bosu ball
Challenges in quadripod, half kneeling ,
kneeling
Kitchen sink exercises - heel rises, toe
offs, partial wall squats, chair risers,
single limb stance and marching in
place.

37. FOR GAIT TRAINING
GO SLOW
Visual cues like stationary floor markings (improve stride length and
velocity)
Auditory cues
Rhythmic auditory stimulation -steady beat or metronomes (improve
gait speed cadence $ stride length
Multisensory cueing
Reciprocal arm movement

38. FOR COORDINATION
Frenkel's Exercise
Tip to tip
Tip to nose

39. FOR PSYCHOLOGICAL WELL BEING & MICROGRAPHIA
Educate to lead a relatively active
functional life
no false assurance
Counselling
Encourage to take dog for a walk
or play with the dog
Lead a active lifestyle
Writting in 4 line copy or square
box copy may help in writting size

40. FOR DYSARTHRIA
P A G E 0 8
LSVT Loud
By Speech therapist

41. FOR THORACIC EXPANSION
P A G E 1 4
Diaphragmatic Breathing
Segmental Breathing
Balloon blowing
Incentive Spirometry
During extension exercises patient
should be asked breathe in - helps in
increasing thoracic expansion

42. FOR FUNCTIONAL TRAINING
Bed Mobility Skills - Rolling, Bridging, Supine to sit transitions
Anterior posterior tilts, side to side pelvic tilts, pelvic clock exercises.
LSVT Big program

43. FOR STRENGTHENING
For anti gravity muscles.
Using of thera band, free weights
2 days/week on nonconsecutive days

44. IMPROVING THE PHYSICAL FITNESS
Aerobic exercises.
Rejoining her dance
class.
walking to her friends
house.

45. THANK
YOU!