to carbidopa-levodopa. Assessment includes testing ROM and muscle length, strength testing, and balance testing. A falls screen is not necessary because of her history of multiple falls, indicating that she is at high risk of falling. In addition, she has reported trouble reaching low shelves, and further questioning indicates that reaching out of her base of support may be an issue. The Functional Reach Test would give an objective measure of her ability and safety while doing functional activities that require reaching. To measure her gait and balance objectively, the 10-Meter Walk Test and Mini-BESTest are useful. Range of motion is limited in the trunk as well as the extremities, and she has mild strength deficits throughout. Mrs. Smith’s functional reach is 5 in. (impaired), and she exhibits difficulty maintaining balance during reaching. Mrs. Smith is unable to balance in the Romberg stance for >10 seconds and ambulates at a gait speed of 0.30 m/sec. Her score of 17 on the Mini- BESTest indicates significant mobility difficulties and a high fall risk. Questions 1. Describe where the emphasis of treatment is for individuals who are in Hoehn & Yahr stage 4. Why does this differ from those in earlier stages of the disease? 2. What areas will be the focus of an intervention plan for Mrs. Smith? Relate this to her findings on assessment and specifically to any outcome measures that were utilized. Responses 1. For individuals who are in Hoehn & Yahr stage 4, the plan of care must take into consideration the advanced stage of the disease, limiting the ability to regain function. Therapy to improve strength, ROM, and balance may be beneficial but should be discontinued when progress ceases to occur. In individuals at this more advanced stage of PD, compensatory strategies are indicated. 2. Special attention would be given to practicing tasks for which Mrs. Smith has difficulty on the outcome measures, such as reaching in front of her on the Functional Reach Test and walking with head turns on the Mini-BESTest. Given the stage of her PD, the long-term goal should be safe and independent gait with a device such as a rollator walker. Because of the cast, she will need to limit her ambulation to indoors on level surfaces and may need foam on the walker handle to allow her to better use that hand to guide the walker. She would be instructed to do her primary weight bearing and steering through the unimpaired right upper extremity. Improving gait speed to >0.4 m/sec would be expected to make limited community ambulation possible and should also be a goal of therapy. To work on increasing Glossary ● Apraxia : Loss of the ability to execute tasks when asked to perform them, despite comprehending the command. ● Hyperhidrosis : Abnormally increased perspiration. ● Hypohidrosis : Decreased ability to perspire despite appropriate stimuli such as warm conditions. ● Micrographia : Small handwriting. ● Ophthalmoplegia : Paralysis or weakness of the muscles that control eye movement. ● Pyramidal signs : Signs associated with damage to the corticospinal tract. These signs include spasticity, increased reflexes, and muscle weakness.
gait speed, Mrs. Smith would practice walking at a speed 10% higher than her comfortable speed. Ideally, this speed would be set by a metronome. Frequent and consistent practice is required to change gait speed. She would be told to take big steps when walking and to make contact on her heels. Improving size of movement is typically the most effective means of improving gait velocity in individuals with PD. It is unlikely that she would be able to increase gait speed to community ambulatory levels of >0.80 m/sec because she is in an advanced stage of the disease and her present speed is significantly slower than this. The use of elevated seating and grab bars will ensure that she can safely transfer throughout the day and evening. Her safety with reaching activities can be improved by moving frequently used objects within easy reach. Mrs. Smith is also educated about the on-off phenomena of carbidopa-levodopa to help her to determine a daily schedule in which she avoids ambulatory activities at those times of day when she is most likely to be experiencing the “off” phenomena. It is safer for some individuals with PD to take their initial morning medications before attempting to get up and waiting until the medications have improved their ability to move before getting out of bed. Individuals with on-off phenomena should not shower until their medication has reached effective levels to avoid slipping and falling in the bathroom. In addition, Mrs. Smith is instructed to sit on the edge of the bed for at least 1 minute and pump her ankles before rising to help decrease the risk of orthostatic hypotension. Mrs. Smith is a good candidate for home healthcare to assess and treat safety issues in the home and to assist in modifying her home environment to make it safer. She would also benefit from the services of a home health aide to assist with bathing, household chores, and shopping until she regains full use of her left hand. Use of a medical alert service is highly recommended for anyone who has fallen or is at risk of falling. Newer services offer devices that sense when the individual has fallen and immediately attempt to contact that person. If the individual does not respond, emergency response is initiated. Mrs. Smith should have a medical alert service because of her history of falls and because she lives alone. Although Mr. Jones and Mrs. Smith both have PD, these case studies demonstrate that the focus of therapy changes across the course of the disease, from being rehabilitation-focused to including more adaptations and compensations. Education and appropriate goal setting are important across all stages of the disease. Both Mr. Jones and Mrs. Smith benefit from the services of physical therapy when it is individualized for their situation and the stage of their disease. ● Sensitivity : The ability of a test to detect the presence of a disease/condition when the disease/condition is actually present. ● Specificity : The ability of a test to detect the absence of a disease/condition when the disease/condition does not exist. ● Systems review : A component of the physical therapy examination that includes a screen of all relevant systems and that should include musculoskeletal, neurological, cardiopulmonary, endocrine, and integumentary systems.
Resources ORGANIZATIONS ● American Parkinson Disease Association
● Delay the Disease 614-566-1189 E-mail: delaythedisease@ohiohealth.com http://delaythedisease.com ● LSVT Global, Inc. 3323 N. Campbell Ave, Suite 5 Tucson, AZ 85719
135 Parkinson Avenue Staten Island, NY 10305 Toll Free: 800-223-2732 Phone: 718-981-8001
E-mail: apda@apdaparkinson.org http://www.apdaparkinson.org
Toll Free: 888-438-5788 Phone: 520-867-8838 Fax: 520-867-8839
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