demonstrated that the rollator walker (a walker with four wheels in which the front wheels swivel) improved walking and safety in individuals with Parkinson’s and Huntington’s diseases (Kegelmeyer et al., 2013; Kloos et al., 2012). Gait variability has been shown to be correlated with increased risk of falling (Schaafsma et al., 2003); the rollator walker produced the least variability in all gait measures, whereas variability was greatest with the six-wheeled, U-shaped walker and the standard walker (Kegelmeyer et al., 2013). People could walk around objects more quickly and with the fewest stumbles with the rollator 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. 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.
fitness program for individuals with PD, the major barriers to participation must first be addressed. A 2013 study by Ellis and colleagues concluded that three factors were most likely to interfere with exercise participation of individuals with PD: low outcome expectation, lack of time, and fear of falling. Although these factors can be difficult to overcome, even 10 minutes per day of activity can positively impact health. Testimonials by individuals with PD who participate in consistent exercise may help others overcome low-outcome expectations. Fear of falling is best addressed by ensuring that there is help for those who need it and that the exercise environment is a safe one. Fall prevention A multifactorial approach is best when addressing fall risk reduction. It is important to assess both environmental factors (freezing triggers in the home, for example) and intrinsic factors (postural instability). One of the most common responses to falls is to prescribe an assistive device, yet little research exists examining their use. Although no research exists to demonstrate that assistive devices actually prevent falls, one study has examined the impact of walking devices on gait parameters and on the ability to maneuver around obstacles. The study 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
CASE STUDIES
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 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
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