PARKINSONISM

Niharika Agrawal

Shweta Kolhatkar

Ansu Chacko

Chi-Hsin Yu

What is parkinsonrsquos

disease

bull It is a chronic progressive

degenerative disorder of the

central nervous system

bull It has an insidious onset

Epidemiology

Affects 1 to 15 million people in the

United States alone1-3

Basal Ganglia

Functions of BG

Motor planning and programming internally generated movement

Input from cortex=gt thought=gt motor plan=gt select and inhibit specific strategies=gt regulate movement (tone force)

Caudate nucleus cognitive- awareness of body orientation in space (righting reflexes) behavior modification as per task requirement motivation

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

What is parkinsonrsquos

disease

bull It is a chronic progressive

degenerative disorder of the

central nervous system

bull It has an insidious onset

Epidemiology

Affects 1 to 15 million people in the

United States alone1-3

Basal Ganglia

Functions of BG

Motor planning and programming internally generated movement

Input from cortex=gt thought=gt motor plan=gt select and inhibit specific strategies=gt regulate movement (tone force)

Caudate nucleus cognitive- awareness of body orientation in space (righting reflexes) behavior modification as per task requirement motivation

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Epidemiology

Affects 1 to 15 million people in the

United States alone1-3

Basal Ganglia

Functions of BG

Motor planning and programming internally generated movement

Input from cortex=gt thought=gt motor plan=gt select and inhibit specific strategies=gt regulate movement (tone force)

Caudate nucleus cognitive- awareness of body orientation in space (righting reflexes) behavior modification as per task requirement motivation

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Basal Ganglia

Functions of BG

Motor planning and programming internally generated movement

Input from cortex=gt thought=gt motor plan=gt select and inhibit specific strategies=gt regulate movement (tone force)

Caudate nucleus cognitive- awareness of body orientation in space (righting reflexes) behavior modification as per task requirement motivation

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Functions of BG

Motor planning and programming internally generated movement

Input from cortex=gt thought=gt motor plan=gt select and inhibit specific strategies=gt regulate movement (tone force)

Caudate nucleus cognitive- awareness of body orientation in space (righting reflexes) behavior modification as per task requirement motivation

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Pathways

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Pathophysiology

Parkinsonsrsquo disease is idiopathic parkinsonism

bullSubstantia niagra pars compacta- degeneration of dopaminergic neurons

bullDopaminergic neurons- cell bodies in SNpc=gt axons in striatum

bullDopamine deficiency- underactive direct pathway=gt bradykinesia overactive indirect pathway=gt rigidity and tremors

bullSlow and progressive disease

bullNeuron degeneration progresses-Cytoplasmic inclusion (Lewy) bodies loss of striatal dopamine receptors=gt decrease in dopamine binding sites=gt loss of effectiveness of medication (L-dopa)

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Signs amp Symptoms

Rigidity

bullCog-wheel vs lead pipe

bulllsquoheaviness and stiffness of limbsrsquo

bullResistance to all passive movement

bullProgression proximal=gt distal=gt whole body

Unilateral=gt bilateral

Stretch reflexes are normal

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Resting tremors- Involuntary oscillation at 4-6 Hz

bullPill-rolling tremors of the hand

bullAggravating factors emotional stress fatigue

bullRelieving factors Relaxation

bullAbsent voluntary activity sleep

bullFluctuations in frequency and intensity

bullPostural tremor head amp trunk upright posture

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Akinesia

Bradykinesia

Hypokinesia Reduced amplitude

Disturbances in attention and

depression=gt compound these signs

Influenced by degree of

rigidity fluctuations in drug action and

stage of disease

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Postural deviations

Weakness trunk

extensor muscles gt

flexor muscles=gt

stooped posture

increased flexion of

neck trunk hips and

knees=gt changes the

center-of-alignment

positioning patient at

forward limits of stability

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Gait Deviations

Generalized loss of extension at hip knee and ankle and decrease in trunk and pelvic motion

Decreased arm swing and stride length

Small and shuffling steps loss of normal heal toe progression

Abnormal stooped posture

Festinating gait (Progressive increase in speed with the shortening in stride)

Takes multiple short steps to catch his own COM

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Complications

Freezing spells Reduced aerobic capacity Falls Osteoporosis Fractures sleep disorders Contractures amp deformities Adverse effects of medication Constipation Facial muscle rigidity leading to Masked

face

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Postural instability

bullAbnormal and inflexible posture responses

bullIncreased body sway Narrow BOS or divided attention increase instability and may compromise balance

bullDynamic balance and perturbations may elicit an abnormal pattern of co-activation- due to

bullDifficulty in feed-forward anticipatory adjustments of postural muscles during voluntary movements-due to RIGIDITY REDUCED MUSCLE TORQUE PRODUCTION WEAKNESS and LOSS OF AVAILABLE ROM IN TRUNK AND OTHER MUSCLES

bullVisuospatial impairment and problem with sensorimotor adaptation Unable to perceive the upright positon due to visual proprioceptive and vestibular perception abnormalities

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Visual defects blurred vision

photophobia conjugate gaze saccadic

eye movements

bullSpeech voice and swallowing

Mutism Dysphagia Sialorrhea etc

Respiratory dysfunction

Depression and social isolation

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

MEDICAL MANAGEMENT

SYMPTOMATIC THERAPY Levodopa Carbidopa ndash

Sinemet decarboxylase inhibitor Adverse effects- orthostatic hypotension

arrhythmias constipation delusions hallucinations

Dopamine Agonist bromocriptine ropinirole

lsquowearing- lsquooffrsquo state or end-of-dose deteriorationrsquo

Later on-off phenomena- appearance and disappearance of signs and symptoms

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

ANTICHOLINERGICS

Ethopropazine benztropine trihexyphenidyl

+ l-dopa =gt reduce motor fluctuations

Adverse effects dizziness blurred vision dryness of mouth constipation urinary retention

ANTI-DEPRESSANTS TCA benzodiazepines

NEUROPROTECTIVE THERAPY

Slows progression

Monoamine oxidase inhibitors (MAO) improves intracerebral metabolism of dopamine

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Surgical techniques

Pallidotomy

Stereotaxic thalamotomy

Deep brain stimulation of STnGPi-

superior to medication

Cortical stimulation

Gene therapy

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

CASE STUDY

Mr K

Age 72 yo male

Diagnosis Parkinsonrsquos Disease (PD) 5 years ago

Hoehn amp Yahr stage 3

On a combination of medication

Activity Able to perform most ADLs alone fatigues

easily has been having Activity limitation

Difficulty in rolling completing sitltgtstand and

walking in small spaces

He recently fell when carrying groceries in from the

car

Mr K was referred to physical therapy and has not

previously received PT

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

ICF model of Mr K

Parkinsonrsquos Disease Stage III

Impairements

Rigidity Akinesia

Impaired motor planning

amp balance Postural

instability Impaired

muscle performance gait

deviations aerobic decon

Activity Limitations

Difficulty in bed mobility amp sit

to stand

Participation

Restriction

Community

ambulation

Environment factors

Personal factors

Age comordities Hoehn amp

Yahr Stage 3 No PT taken

Combination of

Medication Progressive dis

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Test and Measures Balance testing- TUG ABC scale berg

balance functional reach test dynamic gait index

Co-ordination testing- RAMS finger to nose heel to shin test

Task analysis- ADLs IADLs Functional Independence Measure

Disease specific outcome measures

Parkinsons disease questionnaire-39 (PDQ-39)

Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

SF 36

6MWT

Gait observational analysis

Environment assessment

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Prognosis

Difficult

Severity of disease symptoms

Different patient response

No standardization in onset

MrK lsquos prognosis ---- Guarded

Rationale

Elderly

No co- morbidities

High risk of falls

Progressive disease

Stage 3

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Practice Pattern

5 C ndash impaired motor function and

sensory integrity associated with

progressive disorders of the CNS in

adulthood

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Goals

Mr K will roll from supine to side-lying within 5 seconds by performing an effective segmental rolling independently by end of 2 weeks

Mr K will stand from a standard chair bed within 8 secs independently with hand support on a firm supporting surface without loosing balance by end of 2 weeks

Mr K will stand on a firm surface without loosing balance with eyes open

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Goals

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Plan of CarePatient family and caregiver education

Patient and hisher caregivers must be educated about

The clinical presentation and progressive nature of the disease

Importance of mobility and maintaining activity level and modifications ( explain)

Techniques and strategies to manage and maintain the condition

Prevention of complications amp impairements

Importance of exercises

Lifestyle modification

Energy conservation

Active participation in social activities

Encouragement and motivation

Daily diary

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Coordination communication amp

Documentation

Co-ordinate with caregivers and family

about the medications

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Intervention Relaxation techniques

=gt reduce rigidity and increase flexibilitySlow rhythmic segmental rotations

PNF techniques

Ryhthmic inititation

Contract relax techniques

Diaphragmatic breathing

Meditation

Conscious relaxation and release of muscle tension(called chaitanyasan- an asana of yoga) 7 9

Relaxation audio tape

Gentle yoga and tai chi 78

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Sit to Stand

Rocking forward- backward=gt

relaxation=gt enhance ability to shift

weight forwards

Visual and verbal Cues

With gait belt on

7- 10 reps RPE

Progression

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

STRETCHING + STRENGTH

Stretching

PNF trunk range of motion

Progression

Spinal flexibility exercises

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

bullStrengthening exercises- stress on extensor muscles

Warm water strengthening exercise

Bridging sit to stand step up and down-17 to 35 cm- 10 reps downhill walking Intensity 60 of 1 RM

Volume 10-12 reps 2-3 sets 2 minute rests between sets

Exercise session 20 minutes

Frequency alternate days

bullSwiss ball roll exercises one leg stance

bullGym music

bullPelvic floor exercises

Respiratory muscle training

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

BALANCE TRAINING

bullNarrow Base Of Support- eyes open=gt closed

Tandem- eyes open=gt closed

single leg standing eyes open=gt closed

pertubations

standing on foam

bullRocker board

bullHeel and toe raises

bullBall toss on rocker board trampoline and foam

bullMarching on trampoline

Swiss ball exercises

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Computerized

Dynamic Posturography

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Gait training

bulluarrstride length uarrBOS improve heel-toe gait pattern uarrcontralateral trunk mrsquot amp arm swing

bullStepping forward and backward

bullStopping starting changing direction turning

bullSidestepping and crossed- step walkingPNF activity of braiding

bullVisual + auditory cues

bullTreadmill-body weight support-downhill

Medication

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Aerobic ex

bullSubmaximal ex 50~70 HR peak

every alternate day

bull6MWT

bullWalking

bullUpperlower extremity ergometry

for postural instability and high risk of

fall-stationary or seated ergometry

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Home Exercise Program

Relaxation exercise s Flexibility exercises Walking Skills to manage after a fall- Quadruped

creeping Facial muscle exercises- massage stretch manual contacts Mobility exercises - pursing lips

miling frowingwincing chewing biting etc movements of the tongue swallowing

Use of mirror in all these activities Home exercise-Teach self relaxation

rocking chair at home 6

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

Other Evidences Based

interventions Tai Chi

Yoga

Kayaking

Tango style dancing

Karate

Water aerobics

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M

References 1)O sullivan

2)Management of individuals with PD rationale and case studies

3)Voss DE Ionta MK Myers BJ Proprioceptive Neuromuscular Facilitation Patterns and Techniques ed 3- Philadelphia PA Harper amp RowPublishers Inc 1985 FIND IT

4)Bobath B Adult Hemiplegia Evaluation and Treatment ed 2 London England William Heinemann Medical Books Ltd 1978

5)Stockmeyer S An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction Am J Phys Med 46900- 954 1967

6)143 in sullivan FIND IT

7)Relaxation an yoga

8)Tai chi

9)Cochrane Database Syst Rev 2006 Jan 25(1)CD004998

Meditation therapy for anxiety disorders Krisanaprakornkit T Krisanaprakornkit W Piyavhatkul N Laopaiboon M