Group 5 Case 1b Presentation

Hemali MehtaI-Chen Liu

Jinesh GandhiPei-Ren Tsai

Health Condition

G.20 Parkinson’s Disease

Pattern 5A: Primary Prevention/ Risk Reduction for the loss of balance and Falling

Impairments

PostureIncreased thoracic kyphosis and decreased lumbar lordosis

Decreased ROMB Hip Extension (-10) and knee extension(-5) and ankle DF (0)

Decreased Strength B Hip Abductors (3/5), Hip extensors (3/5), hip flexors (4/5) and Ankle PF (3/5)

Impairments

Impaired Gait decreased step length and shuffling gait pattern

Impaired BalanceTUG: 35 seconds Berg: 40/56

Impaired Motor controldifficulty in initiation, freezing episodesR hand resting tremor, R Bradykinesia

Activity Limitation

Community walking

ADLs

Driving

Lifting objects for grocery shopping

Baby sitting

Participation Restriction

Role as a Spouse/ Husband

Role as an independent Individual

Role as an grandparent/babysitter

Contextual Factors

Personal Factors

Age, good health with no co-morbidities, medication for Parkinson’s (senimet), History of frequently near fall

Environmental

Family support (wife to help him), Home environment

Impairments Activity Limitation Participation

Impairer Posture

Spouse / Husband

Independent Individual

Grandpa / Baby sitter

Community walking

ADLs

Driving

Lifting Objects

Baby sitting

Decreased ROM

Decreased Strength

Impaired Gait

Impaired Balance

Impaired Motor Control

Goals

1. The patient will improve muscle strength  of hip extensors, abductors from grade 3 to 4, improve the BBS 5 points or more, to restrict nearly fall situation less than 3 times / week within 6 weeks

2. The client will demonstrate the ability to walk at least 40 ft without freezing 50% of the time within 6 weeks

Intervention

Balance Training: Stepping Ex

Direction: front and sideFeedback: KR for 66% of time(i.e. 3rd trial w/o feedback)

HEP: 5reps in each direction x 1 set, 2time/day(Baseline: The patient performed 6-7 reps for each directions)

Repetitive step training with preparatory signals improves stability limits in Parkinson’s

patients,J Rehabil Med 2012; 44: 944–949

Studies effects of volitional step training on LOS, posture and gait.

RCT with control and experimental groups

Improvement in reaction time, movement velocity and LOS = improvement in balance

3 times/week, 1 hour sessions for 4 weeks

Intervention

Gait training

Cues: External Auditory-MetronomeFeedback: Bandwidth

HEP: Walk 10 ft more than usual, self cues

Cueing training in home improves gait related mobility in Parkinson’s disease: RESCUE trial, J Neurol Neurosurg Psychiatry 2007;78:134–14

Randomized Crossover trial.

Cues given in a home based therapeutic intervention

Cues; self selected ( auditory, visual or somatosensory) given at patients preferred frequency

3 times/week, 30 minutes, 3 weeks

Improvements in gait speed and step length, tandem and one leg standing and reduction of freezing by 5.5%

Motor Planning and Learning

Motor PlanningBasal Ganglia: sensory integrationCentral motor drive: APAs

Motor learning: Procedural/Nonprocedural

REF: Evidence for motor learning in Parkinson's disease:Acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues

Cueing? Dual Task?

Cueing: cues V.S. no cues?In short term, change in gait parameters are better with no cueingIn long term, there are significant changes in gait parameters with auditory cues(retention)

Dual Task:Research has shown that dual task increase retention of PD

REF: Evidence for motor learning in Parkinson's disease:Acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues

Novel Approach

Exercise Principle1. Specificity2. Progressive Overload3. Varied Practice

Stage of Application?

REF: A novel conceptual framework for balance training in Parkinson’s disease: a study protocol for randomized control trial.Conradsson et al. BMC Neurology 2012