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 Brain Comparison

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:

 Patient Health Questionnaire (PHQ-9): 12

 Parkinson's Disease Questionnaire (PDQ-39): 38/156 = 24%

 Most affected areas: mobility, emotional well-being, social support

 Activities-Specific Balance Confidence Scale (ABC Scale): 65%

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 During her initial As appropriate Ongoing To ensure unde

appointment with check effectiveness of
1. Role of the Physiotherapist
ins as needed program while
(PT)

2. Energy conservation
methods

3. Environmental
modifications

Gait 4 days/week Light intensity 400m Problem list (2,4

total
 Nordic walking Training of gait
in its prevention
 Musical cueing
effective in imp
coordination, w
Balance Training In clinic Working within the 30 socialization[3]. M
limits of her stability minutes improvements
From BBS:  1x/week for the
aspects also add
first month
1. Tandem stance confidence.
At home
2. Turning 360 degrees
 1x/week for the
3. Standing with feet
 together first month

4. Standing with eyes closed  To progress to be

functionally
Examples (tandem stance, visual
included in her
cues, balance boards, single leg
everyday
stance)

Community Dance Program 2x/week Moderate intensity 1hr Problem list (1,

Participation in
improvements
decrease the ris
this activity is p

Strengthening 3x/week 60% of 1RM 3 sets of Problem list (2,

10
1. General strengthening - When gait and
Kitchen sink exercises motor control le
falls [15]. As well
2. Grip strength
improve balanc
3. Postural can further help
strengthening/Motor strength appea
control strengthening h
functioning in t
independence a

ROM 3x/week Reach a point where 20s static Problem list (2,
you can feel the stretch x3
1. Shoulder Improving Mrs.
stretch but not past sets
balance training
2. Hip the point of pain
OR in performing h
3. Dorsiflexion
60s
4. Trunk rotation dynamic
stretch

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

1. ↑ Jump up to:1.0 1.1 1.2 Physiopedia. Parkinson's. Available from: [Link]

[Link]/Parkinson%27s (accessed 13 May 2020).