Case Assignment On Parkinson’S Disease

My case involves a 74 year old male, a former successful member of the corporate world, who was diagnosed with Parkinson’s disease and initially was confined to a wheelchair. He also had a history of bipolar disorder and depression which inhibited his enthusiasm to participate in PT. He presented with tremors and had a history of falls. My foreground question was: Would a bipolar, well-educated 74 year old male with Parkinson’s Disease, who presents with depression and anxiety and was wheelchair bound, achieve safe, independent functional ambulation faster with gait training, PNF and PROM combined with Music therapy or with just PNF, PROM and gait training alone?

One test that I used to determine my patient’s prognosis was the TUG test (Timed Up and Go). The purpose of this test is to measure a patient’s fall risk and his or her progress in dynamic balance, the ability to transfer sit to stand, and ambulation. Originally, this test was designed for elderly persons, but currently it has been used with those suffering from Parkinson’s, Multiple Sclerosis, Stroke and even hip fractures. It seemed like an easy test to administer for someone with functional cognitive status, such as his. According to the National Parkinson Foundation Toolkit for the TUG test, patients who completed the test-(standing up from the chair, walking 10 feet, turning around and walking back and sitting) in approximately 10 seconds or less ((9. 2 seconds 95% Confidence Interval (8. 2-10. 2) for those in the 70-79 age group)) would be labeled as functional ambulators and have less chance of a fall. Since my patient was originally wheelchair bound and unable to ambulate safely, I used this test’s normal ranges for his age to guide me in my plan of care and plan for discharge. As per Rehabmeasures, to detect a minimal detectable change, MDC (change not by error) my patient would have had to decrease his TUG time by 3. 5 seconds.

I originally chose this test because of its reliability and validity as it is used in the National Parkinson’s Foundation Toolkit. In a study by Huang et al, 2011, with 72 Parkinson’s patients tested, with an average age of 67. 2 years, the TUG test had detected an ICC of. 80. These patients were 1 hour into their medication. This is a good reliability score as compared to. 90, which is excellent. Also worth noting was intratester (same person) and intertester (among others) reliability in elderly populations, with an ICC from. 92-. 99. Construct validity as per Rehab measures was reported to. 78 when compared to the Berg Balance Scale which would also be positively significant. When predicting fall risk, the TUG had a sensitivity of. 69 and a specificity of. 62. A highly sensitive test will, if negative, rule a disease/risk out (Snout) and a highly specific test, when negative will rule a disease/risk in (SPin). So these tests are slightly higher than 50/50 chance of detecting fall risk. I chose music therapy as my intervention (incorporating dance and rhythm and certain genres) to be included with my traditional interventions because of my previous experiences with similar patients. I have found that this intervention not only includes the components of dynamic balance enhancement, aerobic exercise, executive functioning and fluid movement, but it also elevates the mood of the patient (as well as the therapist).

In the Clinical Practice Guidelines for Parkinson’s disease, the use of Music therapy is mentioned as part of PT/OT treatments, but is assessed with a check mark, indicating a preferred treatment based solely upon clinical experience, suggesting the need for more advanced studies In a systemic review in 2016 by Kogutek, Holmes, Grahn, Lutz and Ready, it was suggested that, “active MT (music therapy) can improve motor skills and should be considered as a potential treatment. ” This review studied research up to 2014 and patients 18 years old and over totaling 258 patients. In a systemic review by Nobela, 2013, “Rhythmic auditory training improves gait velocity, cadence and stride length in Parkinson’s patients. ” 2 Since gait disturbances involve timing of movement and balance, we still need larger samples and additional studies to verify the success of this intervention. I would not change my decision to use music therapy; I would appreciate additional studies on the success and validity of this intervention. I wish I personally had time to use my “clinical experience” to take it further with research.

A realistic outcome measure for this case would be the Functional Gait Assessment (FGA) which measures postural stability during walking. This measure of 30 items involves many changes in direction and rotational components, which could mimic dancing to music which I have found successful when working with cognitively intact patients who need an intervention to lift their spirits as well as their status. A study by Yang et al in 2014, found that scores of 18/30 or less on the FGA can identify fallers in Parkinson’s disease with a higher sensitivity. 80 and a higher specificity of. 806 than the TUG test. When considering reliability, Huang, et al. 2010 had an ICC of. 84 and according to Kadivar, et al in 2011, the FGA had an ICC of. 99. When compared to the Berg Balance Scale for validity, a study by Wrisley and Kumar in 2010 revealed patients who scored less than 22/30 points on the FGA were 6 times likely to fall. Peterson, in 2016, detected a MDC of 4 points in a study with 22 subjects.

Since my patient began his treatment with me as non-ambulatory Parkinson’s patient, I would probably stay with the FGA as my outcome measure of choice because of the many gait components it can measure. Another outcome measure, The Unified Parkinson Disease Rating Scale, will be gaining popularity as a measurable outcome as additional studies are done. In regards to the three main sources of evidence, I have relied heavily on my clinical expertise and scientific research which lead to choosing music therapy to help ease my patient’s anxiety and depression. It allowed me to remain sensitive to patient values and circumstances.