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Case Study

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Ji-Nee Lo

on 26 April 2015

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Transcript of Case Study

Students: Allen Hidalgo, Ji-Nee Lo, Leora Rosen, Tara Salay, Vivek Sukumaran
Advisor: Dr. Corio

Case Study
Pt is a 72 y.o. male admitted into

The patient has been diagnosed with
Parkinson's Disease
for 24 years. His Parkinson’s symptoms have progressed and
in the past 3 years.

Admission to Hospital
Chart Review:
Date of admission
Previous Visits
Medical history
Nurse's notes
Braden Scale: predicting risk for pressure sores
Tests administered at admission:
CT scan
Blood Test/CDC Count
Tolcopone- 100mg

Levadopa- 100mg

Rivastigmine tartrate patch

What time of day
are meds administered?
History of
Current Condition
Level of Assistance
Arousal, Attention, Cognition
Gait and Balance
Pt. began developing flu-like symptoms 2 weeks ago
Cough continued to worsen → MD visit
Chest x-rays showed bacterial pneumonia → admission to hospital
Pt. does not use assistance device for ambulation
Pt. uses furniture at home to maintain balance
Outside of home, pt. uses wheelchair
Requires assistance from partner to transfer into tub, dressing, and personal hygiene
Social History
Pt. lives with partner of 42 years
Condo in Manhattan with elevator
Onset of dementia from PD within last 3 years
A&O x 1
Easily confused
No conversation initation
Decreased facial expression
Shuffling gait pattern
Decreased speed
Minimal weight shift L to R with ambulation
Decreased reciprocal UE swing and trunk rotation
3 times in the last 6 months
slow to no reaction to perturbations
Range of Motion
Overall Joint Stiffness
Muscle Performance
UE and LE gross MMT = 3+/5
Only tolerates minimal resistance
Increased kyphosis
Forward Head
Chief Complaint
: Bilateral shoulder and neck
General body aches
Worse at end of day
Sensory integrity and dermatome testing intact
Reflexes = 2+
Pill rolling tremor of R hand
Rigidity of both UE and LE
Bradykinesia with movements
Bruising in various parts of body, arms, thighs, face
Tests and Measures
Berg Balance
: 35/56
Moderate risk for falls
Balance = 6/16
Gait = 4/12
High risk for falls
Aerobic Capacity
Fatigues very easily
Chest expansion with inhalation: <1 inch
Normal = >2 inches
Increased use of accessory muscles during respiration
2L O2 via NC
SpO2: 98% at rest
85% with activity (bed to chair transfer
Stage of Parkinson's Disease
Hoehn and Yahr Scale
Objective pain scale
Neurological Exam
Integumentary Assessment
Cardiopulmonary Testing
Endurance Testing
Patient Goals for Discharge
Outcome Measure

Parkinson’s Disease: > 16 seconds
= fall risk
Assesses pt’s performance during a transitional movement
Evaluates balance and bradykinesia
Useful in determining fall risk in patients with PD

Five Times
Sit to Stand Test
"Five Times Sit to Sand Test Performance in
Parkinson’s Disease" (Duncan et al, 2011)

High test retest reliability and high interrater reliability
Sensitivity = .75
Specificity = .68
The FTSTS is comparable to other accepted outcome measures in distinguishing between fallers and non-fallers

Other Tests and Measures
Timed Up and Go

Administered for quantitative along with qualitative information
Observation of pt’s gait pattern
Observe for akinesia or freezing

Short-Term Goals
Pt will maintain 88% O2 saturation with activity using 1 L of O2
Pt’s chest expansion will be increased to 1.5”
Pt will ambulate 10’ with RW modAx1
Pt and caregiver will be educated on safety during transfers and ambulation

Long-Term Goals
Pt will maintain 96% O2 saturation with activity without supplemental O2
Pt’s chest expansion will be increased to 2”
Pt will ambulate 50’ with RW with supervision
Pt will be able to perform functional activities with minimal assistance
Pt will be ind in a HEP

Sit to Stand

Monitor O2 saturation
Provide intrinsic and
extrinsic feedback
Break down into parts:
-Hip flexion to bring body
-Lift pelvis
-Extension of hips/knees
-Maintain stance
Functional exercise to improve efficiency of ADLs
Specific training for dynamic balance

Adler, S., Beckers, D., Buck, M. PNF in Practice: An Illustrated Guide. Springer Science & Business Media. Oct 27, 2013

Bhatt, T., F. Yang, M. K. Y. Mak, C. W.-Y. Hui-Chan, and Y.-C. Pai. "Effect of Externally Cued Training on Dynamic Stability Control
During the Sit-to- Stand Task in People With Parkinson Disease." Journal of American Physical Therapy Association 93.4 (2013): 492-503. Web. 4 Dec. 2014.

Duncan, Ryan P., Abigail L. Leddy, and Gammon M. Earhart. "Five Times Sit-to-Stand Test Performance in Parkinson's Disease."
Archives of Physical Medicine and Rehabilitation 92.9 (2011): 1431-436. Web. 4 Dec. 2014.

Mirek, E. Chwala, W. Longawa K., Rudinska, M., Adamkiewicz, P., Szczudik, A. "Proprioceptive neuromuscular faciliation method of t
therapeutic rehabilitation in treatment of patients with Parkinson disease" Neurol Neurochir (2003): 37 Suppl 5:8-102. Web. 1 Dec. 2014

Mundy, L. Leet, T., Darst, K., Schnitzler, M., Dunagan, W. Early Mobilization of Patients Hospitalized With Community-Acquired
Pneumonia. Chest. 2003; 124(3):883-889.

Noll, Donald R, Brian F Degenhardt, Thomas F Morley, Francis X Blais, Kari A Hortos, Kendi Hensel, Jane C Johnson, David Pasta,
and Scott T Stoll. "Efficacy of Osteopathic Manipulation as an Adjunctive Treatment for Hospitalized Patients with Pneumonia: A Randomized Controlled Trial." Osteopathic Medicine and Primary Care 4.2 (2010): 13. Print.

"UNIFIED PARKINSON'S DISEASE RATING SCALE." Web. 10 Oct. 2014. <http://www.etas.ee/wp-content/uploads/2013/10 uprs.pdf>.

PT Diagnosis & Practice Pattern
Primary Practice Pattern
: 6C
Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity Associated with Airway Clearance Dysfunction

Secondary Practice Pattern: 5E
Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System

Primary PT diagnosis:
Decreased endurance, decreased function, balance, decreased thoracic expansion, decreased ROM, secondary to Parkinson's and pneumonia
Pneumonia with progression of Parkinson's Disease
Decreased Endurance
Decreased O2 Saturation with activity
Inability to perform ADLs independently
Functional Limitation:
Inability to transfer from bed to chair
NAGI Model
Home Exercise Program (HEP)
Diaphragmatic Breathing
Criteria for Discharge:

Demonstrate diaphragmatic breathing to patient
Describe each step and provide written instruction

Pt position:
One hand on sternum and second hand on abdomen
Have patient perform exercise and observe quality of movement

Meet Short Term Goals:
Home Exercise Program
PNF: B/L D2 FLEX/EXT to Improve Respiration
and Postural Training
D2 FLEX goes with inhalation
Shoulder: FLEX/ABD/ER
Wrist: Ext/ Radial DEV
Elbow: flexed, extended, flexing or extending

D2 EXT goes with exhalation (or a cough)
Shoulder: EXT/ADD/ IR
Wrist: FLEX/ Ulnar DEV
Elbow: flexed, extended, flexing or extending

Progression of Parkinson’s:
Educate the patient and partner (caregiver)
Patient Education Parkinson's Program (PEPP)
Improves quality of life in patients and creates less psychosocial problems for the caregiver.

Evidence Based Article
The benefits of a standardized patient education program for patients with Parkinson's disease and their caregivers. Parkinsonism & related disorders

Progression and Quality of Life

LSVT (Lee Silverman Voice Treatment) Big improves speed of movements in patients (i.e. Increased stride length and increased gait velocity) with PD.

Evidence-Based Article
: Training Big to Move Faster: "Training BIG to move faster: the application of the speed–amplitude relation as a rehabilitation strategy for people with Parkinson’s disease"

Tai chi training appears to reduce balance impairments and improve functionality in patients with mild-to-moderate Parkinson's

Evidence-Based Article
: “Tai Chi and Postural Stability in Patients with Parkinson's Disease”

Patient Education
Referral from physical therapist to assess safety of home

Ways to change home:
Get rid of throw rugs
Create ample space
available for walking
Proper footwear
Night lights

Home Health Assessment - Prevention of Falls
Fourth most common hospital diagnosis
Percentage of hospital inpatient deaths from pneumonia = 3.4%
Average length of stay = 5.2 days
Represent a cost of $40.2 billion dollars in US economy
Become more resistant to antibiotics
Describe our case study and the background information of the patient
Explain what other information we need to know
Explain the use of the Five Times Sit to Stand Test as an outcome measure
Outline the treatment plan and progression for the patient
Analyze each intervention utilized

Summary of 30 min Treatment Session
Interventions to...
- increase O2 saturation with endurance
- decrease dependency on oxygen tank
- increase chest expansion
Diaphragmatic Breathing
- improve stamina with ADL
- expand lung air pockets and improve flow of blood and lymph
- prevent infection

Rib Mobilization
- improve mechanical dysfunction at rib
- encourage expansion to increase inhalation and exhalation

Thoracolumbar Soft Tissue:

Soft Tissue Massage
massage, stretching, kneading, and direct inhibitory pressure to relax the muscular and allow further expansion

Doming of Diaphragm:

improve diaphragmatic movement and lymphatic drainage

reducing tissue tension
Myofascial release:

Health Condition:
Pneumonia with progression of Parkinson's
Body Functions
and Structure:
• O2 saturation with activity
• Endurance
• Thoracic expansion
• Balance
• Postural control
• Muscle strength
• Core stabilization
• Gait speed
• Cognition

- Functional Mobility
• Requires assistance to transfer from bed to chair
• Requires assistance for all functional activities

• Requires wheelchair outside of home
• Unable to participate in social and leisure activities

Contextual Factors
Environmental Factors:
• Dependent on assistive device
• Medications needed daily for Parkinson’s

Personal Factors
• Dependent on partner for functional activities
Tai Chi
1. Pt will maintain 88% O2 saturation with activity u 1 L of O2
2. Pt’s chest expansion will be increased to 1.5”
3. Pt will ambulate 10’ with RW modAx1
4. Pt and caregiver will be educated on safety during transfers and ambulation

Adaptive Equipment Needed:
U-Step Walker with light
Patient Education
Thank you.
Special thanks to our advisor, Dr Corio!
Interventions to...
Facilitation of Diaphragm

- decrease use of accessory respiratory muscles
- increase chest expansion with inhalation

Proprioceptive Neuromuscular Factiliation
Aim of therapy is for patient to achieve optimal functional ability using manual contact
PNF in Practice: An Illustrated Guide
Facilitate diaphragm and intercostal muscles
Proprioceptive Neuromuscular Facilitation
Scapular Pattern: Anterior Elevation/Posterior Depression
Promotes scapular retraction for posture training
Upper Extremity D2 Flexion:
Shoulder flexion, abduction, ER
Wrist extension with radial deviation
Unilateral --> Bilateral
Combining scapular and pelvic pattern
- improve kyphotic posture
- improve neuromuscular facilitation during progression of Parkinson's

Proprioceptive Neuromuscular Facilitation

"Proprioceptive neuromuscular facilitation method of therapeutic rehabilitation in treatment of patients with Parkinson's disease"
Mirek et al 2003
Proprioceptive Neuromuscular Facilitation
Describe who our patient is and his current condition
Be able to explain the Sit to Stand Test and its outcome measures
Describe our interventions, treatment plan and HEP
Demonstrate facilitation of the diaphragm
Be able to recognize further services for patients with Parkinson's

: place the person in sitting and have them perform the exercises (anti-gravity)
Treating for Pneumonia in acute setting
Treating progression of Parkinson's
Encompassing both pneumonia and Parkinson's
Soft Tissue Massage
Rib Mobilizations
Diaphragmatic Breathing
Postural Training
Referral for other services (LSVT-BIG, Tai Chi)
Proprioceptive Neuromuscular Facilitation
Sit to Stand
15 min
5 min
10 min
Full transcript