An invasive surgery with the potential for life-threatening side effects, pallidotomy surgery has been used only rarely since the advent of deep brain stimulation procedures. However, because pallidotomy surgeries were performed in the recent past, therapists may treat individuals who, having had a pallidotomy, are now unable to benefit from additional symptom relief through deep brain stimulation.
a person is still responsive to dopaminergic medications, yet continues to have disabling symptoms or motor fluctuations despite taking medications. For example, individuals may experience prolonged “off” times during the day that prevent them from being able to walk or stand. Because the procedure reduces parkinsonian symptoms (tremors, rigidity, bradykinesia), individuals can take less carbidopa-levodopa. Decreasing their dopamine therapy can help those who have difficulty with significant dyskinesias, a side effect of the medication that can develop over time. The impulse generators (stimulators) typically last 3 to 5 years before requiring replacement. There are some limitations to deep brain stimulation: (1) most patients must still take medications; (2) the amount of reduction in symptoms is never better than what can be achieved with levodopa- carbidopa; and (3) unilateral implantation often fails to mitigate gait and balance problems.
Pallidotomy surgery permanently destroys the overactive globus pallidus internus to eliminate rigidity and significantly reduce contra-lateral tremor, bradykinesia, and balance problems. Thalamotomy surgery destroys part of the ventrolateral thalamic nucleus to relieve contralateral tremors. Destruction of this small area of the thalamus enhances the benefit of medication for the treatment of tremors and helps to lessen tremors. Because this surgical procedure addresses only tremor, it is rarely used to treat individuals with PD. It would be used only in individuals whose primary disability was because of tremor; in PD, the disability is usually due to bradykinesia and postural instability along with some individuals also being significantly affected by the presence of tremors. The advent of deep brain stimulation has further lessened the use of thalamotomy in treating PD. INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH
condition, the body functions and structure, and participation. Therefore, becoming independent in transfers can improve strength and ROM through repetition of transfers and allows a return to golfing as a result of regaining the ability to get in and out of the golf cart independently. The sections of this course on examination and treatment are based on the ICF classification system (see Figure 4.) Figure 4: Who ICF Classification System
Examination and treatment of individuals with health problems are based on the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF), shown in Figure 4. This system was created to better define terminology across healthcare providers and to guide care and reimbursement. In this classification system, function and disability are viewed as a complex interaction between the health condition (e.g., PD) and the contextual factors of the individual, the environment, and the personal situation. Body structures are anatomical parts of the body such as organs, limbs, and their components; body functions are physiological functions of body systems (including psychological functions). Activity is the execution of a task or action by an individual and would include walking and transfers. Participation is involvement in a life situation such as work or child care. Environmental factors include the natural environment in which the person lives and functions, as well as the technology used, whereas personal factors include family support and culture. Physical therapy is typically initiated based on the patient receiving a diagnosis of PD (the health condition). Knowing this, the therapist would ask the patient about difficulties he or she is having and what the patient’s goals are for therapy. The patient may report issues such as difficulty walking and rising from chairs (activity level issues) and inability to enjoy recreational activities such as golf (participation level issues). Based on this information, the therapist would conduct an examination of areas such as strength, ROM, reflexes, and balance (body functions and structure). The therapist would also include questions about where the person lives, whether the house has stairs, whether anyone else is in the home to help the individual (environmental factor), and whether the person feels depressed (personal factor). The WHO ICF shows that each of these areas has an impact on all the others. The model makes clear that changing the activity level function impacts the health
WHO = World Health Organization; ICF = International Classification of Functioning, Disability and Health Note . From Towards a Common Language for Functioning, Disability, and Health: ICF, by World Health Organization, 2002, p.9. Copyright 2002 by World Health Organization. Reprinted with permission.
EXAMINATION OF THE CLIENT WITH PARKINSON’S DISEASE
The client with PD benefits from examination by a physical therapist at the time of diagnosis with ongoing periodic re- examination throughout the course of disease. This process ensures early detection of declines in function and allows therapy to address them before they lead to significant functional loss or Client history In addition to the routine questions for any patient about demographics, medical history, physical therapy history, general activity level, and fall history, there are PD-specific questions that should be reviewed. It is important to screen the patient for many of the nonmotor problems previously discussed, such as cognitive changes, fatigue, sleep problems, apathy, depression,
deterioration in health. Consistent and ongoing use of evidence- based outcome measures optimizes management of the client with PD, allowing the therapist to note changes over time and improving outcomes for clients with PD.
and anxiety, because they will impact the client’s experience with physical therapy. The clinician should also document the client’s medication regimen (including dosage and timing) as well as any unwanted medication side effects, such as hallucinations, dyskinesias, or dystonias. Determining the medication schedule is particularly important for individuals who use carbidopa-
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