SAMPLE CASE STUDY | Sanjananeurophysio

Parkinson's Disease

This is a case description of somebody I recently started treatment with. Let's call him XYZ. XYZ is a 73 year old male diagnosed with Parkinson's disease 3 years ago. I was approached by him a few weeks after he started experiencing extreme back pain and shoulder pain. He complained of "feet not listening to him" while walking. He said "My feet would get stuck and I had to force them to get back in motion". This was not accompanied with heaviness (often something you observe with freezing of gait) in lower limbs. His chief complains presented to me were freezing of gait and postural pain.

Assessment:
I decided to assess him at his residence due to unfortunate weather. He opened the door to let me in (my observation since it was a narrow passage at his entrance). This was proceeded by a few assessment tests I conducted. I did not have sent from him to record him during the assessment, but I have pictures from functional scales that I used and what I found.

The assessment tests employed are listed below:

360 degree Turn Test/ Freezing of Gait Assessment
9 hole peg test
Mini BESTest
Freezing of Gait Questionnaire
Trail Making Test
Sit to stand, 5 repetitions
Functional Gait Assessment
Parkinson's Fatigue Scale
Posture Assessment
Quality of life

1. 360 degree turn test:

**The source for the assessment sheet is: Claire McClean, founder of RoguePT Wellness. These sheets are subject to copyright, you cannot use them for personal cases.

The path for the test can be shorter. I did not use a proper 1m walk before and 2m walk after. The results are posted below the test description. The description of my scoring is listed above as well.

I did not perform condition 2 or condition 3, because I did not want to combine a cognitive and motor task just yet in the patient.

2. Nine hole peg test - for finger dexterity and speed
- I did not have the original 9HPT, and I had to use something else instead. I decided to take a paper made 3x3 circles, ask the patient to put pawns (to not confuse between other shapes and sizes) on the piece of paper. This was not as accurate as the original 9PHG. The test results are posted below

The 9HPG was resulted in a higher time taken to assemble the pawns in the circles, this indicates a slowness in finger dexterity as compared to normal age norms, and this test was done because the patient complained of a slowness in movement while buttoning his shirt.

3. Mini BESTEST
- I do not want to go in a lot of detail for explaining the Mini BESTEST. The results, however, are shown below. The total scoring for this test was 9/28, which is lower than the normal age norms, and signifies a high imbalance in patients with Parkinson's. This was particularly observed with reactive postural control, and often is an indication of slip-trip training.

4. Freezing of Gait Questionnaire:

- I love questionnaires, because they often guide us on the patient's perception of their condition. This questionnaire helps me understand what the patient thinks of freezing, what he feels, what are his main concerns, and is often a very important step in goal-setting.

The scoring in the FOG questionnaire gives a good starting point on how and where to start working to combat the freezing. This also describes the patient's motivation level and how observant he has been with his condition. With this patient, particularly, footwear was reported to be an issue. With footwear, he would take longer to come out of his "freeze", making it difficult to fully participate in the community. The goal here was to make him confident when he freezes, and confident to wear footwear while walking.

5. Trail Making Test A&B

- TMT tests are often great indicators of cognition. The Time it Takes to finish the two components of the test has also been used to assess a patient's driving capability. In my patient's case, he said that he still drives his car (has not stopped since diagnosis), and it was important for me to make him realise the safety of driving along with Parkinson's. More can be found on this (The Clinical Utility of the Trail Making Tests As Predictors of Driving Performance in Older Adults by Papadonatos et al 2015) article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661063/#R3

The results of the trail making test are given below:

The time taken for Part A was 45 seconds, for Part B 110 seconds. These ranges were below average, however, good enough to allow driving according to the above stipulated research article. The patient seemed to understand instructions and did not seek help/ report any trouble in understanding letters or numbers. Ideally, a Montreal Cognitive Assessment test should be done and will employed in sessions henceforth.

6. Sit-to-stand (5 repetitions)
- A very simple test to assess lower extremity strength. The patient reported no trouble in performing the sit to stand test. Results are shown below.

7. Functional Gait Assessment

- I decided to go with the functional gait assessment over the Dynamic gait Index. The results are reported below.

With significant impairments on the scale, ambulating backwards was most concerning. This also led to me not being able to perform the 4-step square test. It was a challenge to make the patient walk backwards, and be able to maintain balance without falling while doing so. A surprising control over obstacle stepping over 2 inches was observed.

8. Posture Fatigue Scale- This was done to get a general idea of how he feels during daily activities.

9. Posture Assessment- A thorough musculoskeletal assessment including wall to triages test, test for captocormia, and grip strength using a handheld dynamometer, a general posture sheet was filled out to mark deformities. His bilateral arm swing was somewhat intact with an absence of tremor.

10. Lastly, Quality of life assessment - I said that I love questionnaires!

The aforementioned assessment tests are by no means ALL that you can do. A great source by ANPT for core measurements called PDEDGE will help you guide through assessment tests. I will be uploading a general initial thought for treatment plan- of course, this will change with trial and error. Please feel free to Contact me if any doubts.

Treatment Ideas:

- Advised to treat patients "ON" their medication state, this accounts for maximum potential for recovery.

Treatment ideas:

A few changes in the previous assessment were noticed when the patient started attending sessions I n the clinic. The exercise protocol listed below will explain the changes further.

VISIT #1

Date: 30/06/2023

Time: 12 PM (Just after levodopa dose)

1. Endurance/ Aerobic Training:

Equipment: Treadmill (15 minutes) Agility Ladder (side stepping and then middle stepping)

Stats (Time, Speed, HR, etc): 15 minutes/ 1 to 1.8 speed

- Sit to stand (9 reps in 30 seconds) - probable effect of a changed environment

2. Transfers Training:

- Sitting exercises on a chair: bend down and get back up - spread your hands
- Standing: Squat and out (spread hands out)
- Quadruped: Tall kneel and spread hands
- Prone: Days of the week sorting (cobra position)

3. Weight shifts/ Multi- Direction Stepping/ Turning Training:

- Using step-ups Catch and throw in agility ladder; agility ladder side stepping

4. Overground Gait Training/ Strategies:
- Turn Training with obstacles (set up cones in a circle)

5. Cognitive:

- Days of the week and months of the year sorting

6. Dual Task Training:

- Treadmill + bands (kept bands beside treadmill and give them to me one by one) sort

- Facilitates unsupported walking on the treadmill.