walker. The standard walker and two-wheeled walker produced the most unsafe walking patterns (slow with irregular stepping and small steps). Falls that required a therapist to catch the subject occurred in the no-device and cane conditions. Conclusion PD is the second most prevalent of the neurodegenerative diseases in the world, affecting 1.5 million people in the United States alone. With newer treatments and improved life expectancy, it is more important than ever to encourage individuals with PD to adopt a long-term plan for maintaining or improving their ability to participate in activities and enjoy life. Because exercise is the only treatment that has been shown to slow the progression of PD, physical therapy should be a part of every patient’s care, starting from the time of diagnosis. Initially, the primary focus of therapy is aimed at preventing problems commonly associated with PD, such as slow and small movements and tight joints. However, another important goal is to create a long-term fitness program. Standardized outcome measures such as walking velocity, the Brief-BESTest, the UPDRS ADL scale, and the PDQ-8 should be included as soon as a diagnosis is made. They should then continue to be used on a Case study 1: Part 1 Robert Jones is a 70-year-old male with PD in Hoehn and Yahr stage 2 who recently saw the neurologist. At that visit, Mr. Jones was given a referral to physical therapy for gait and balance training; in addition, his carbidopa-levodopa treatment was modified to increase both dosage and frequency of dosing. Mr. Jones lives alone in a two-story home with a full bath and bedroom on the top floor. His daughter accompanies him to his first therapy session and expresses safety concerns. Mr. Jones is asked whether he has fallen in the past 6 months and states that he hasn’t “fallen,” but when his daughter gives him a look he admits that he has had several near falls where he landed on furniture or caught himself on the wall. His falls occur immediately after standing and when he goes to get his mail. In addition, they tend to be more frequent immediately before when he is due to take his next dose of carbidopa-levodopa. A systems review should be performed to determine whether an in-depth assessment in any areas of bodily function is warranted. On screening, Mr. Jones has 5/5 strength in the major muscle groups. He tolerates the Pull Test well, taking only one step. Questions 1. What are possible underlying causes of his falls? What are some things he could be instructed to do to minimize fall risk because of these factors? 2. Which outcome measures would be indicated? Responses 1. Mr. Jones states that his near falls happen immediately after standing and when he goes to get his mail. This history would indicate a possibility of issues with orthostatic hypotension and with navigating uneven surfaces. Mr. Jones feels that the falls have been occurring closer to when his next dose of carbidopa-levodopa is due. This Case study 1: Part 2 Examination finds that Mr. Jones had a blood pressure reading of 120/80 in supine, which dropped to 90/55 when going sit-to- stand, indicating orthostatic hypotension. He has a short stride length with shuffling and a forward velocity of 0.9 m/s. The velocity indicates that his gait speed is slow and puts him at a higher risk of negative health outcomes such as hospitalization. His backward walk velocity is 0.4 m/s, which also indicates an increased risk of falling. His shuffling gait would make it difficult to walk on uneven surfaces and may be contributing to his loss of balance in those situations. To further assess fall risk, the Mini- BESTest was administered. Mr. Jones scores an 18/32 on the mini-BESTest and is found to be at increased risk of falling.
The use of a falls diary can be helpful in determining a pattern to the falls experienced by the individual with PD. For example, are falls related to the timing of the medication or at the end of the day when the client is more fatigued? Determining a pattern with the direction of falls can also be helpful in guiding intervention to reduce falls. periodic basis to better track disease progression and the effect of therapies and exercise on the course of the disease. As individuals begin to experience declines in bodily function and their ability to participate in activities, the therapy program will expand to include a more task-oriented focus, incorporating evidence-based approaches such as LSVT BIG™, treadmill training, or a Parkinson-specific exercise program. Components of any program should include flexor stretching, individualized balance exercises, practice of larger movements, and the use of repetition and functional practice. Because compliance is often an issue, programs should be designed individually to be enjoyable and well tolerated by the individual client. Physical therapists have much to offer the individual with PD, using appropriate assessment and individualized therapeutic exercise that is designed specifically for the impairments and activity limitations associated with PD. indicates that he is beginning to experience “off” periods on carbidopa-levodopa. He should be educated regarding this phenomenon and the need to modify functional activities during off periods. Typical modifications include sitting on higher, firm surfaces and making sure that there are grab bars or other safe objects strategically placed in his home to assist in transfers and gait when needed. If the off periods become significant or frequent, the therapist should evaluate Mr. Jones during an off period in order to offer better strategies to improve independence and safety in functional activities during these periods. 2. Given Mr. Jones’s recent history of stumbles and near falls, a more in-depth examination of balance should be conducted. Initial examination should begin with testing for orthostatic hypotension to ensure that issues with blood pressure are identified before moving on with therapy in order to address these issues during the rest of the examination. Additionally, his history suggests a need to assess gait speed with the 10-Meter Walk Test. Based on the PD EDGE taskforce, use of the Mini-BESTest would provide a means of assessing gait and balance along with fall risk assessment. In addition, the Mini-BESTest would include a TUG and a TUG Cognitive for fall risk during dual tasking. To cover all areas of the ICF, a measure of participation should be included; the easiest test to administer that is valid in PD is the PDQ-8. Results of this questionnaire will allow the therapist to gauge the impact the disease is having on Mr. Jones’s overall quality of life. His responses to the PDQ-8 indicate that PD is interfering with his functioning and contributing to feelings of depression and embarrassment. Questions 1. What should be done to manage his orthostatic hypotension? 2. What interventions could be implemented to improve velocity and stride length? 3. Design a home exercise program for Mr. Jones to maintain function and prevent decline because of PD. Responses 1. Given the examination findings, the treatment plan would first include education to make slow position changes. Mr. Jones would be instructed to perform ankle pumps and lower extremity isometric movements before standing in
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