This document presents a case study and treatment plan for a patient with Parkinson's disease. The patient experiences impairments in posture, range of motion, strength, gait, balance, and motor control. This limits his ability to do activities like community walking, ADLs, driving, and lifting objects. It also restricts his participation as a spouse, independent individual, and grandparent/babysitter. The treatment plan involves balance training exercises and gait training with cues to improve strength and balance and reduce falls. The goals are to improve strength and balance scores and restrict near falls. Interventions are supported by research showing improvements in stability, reaction time, and gait parameters from step training, cueing training, and incorporating exercise

1. Group 5
Case 1b Presentation
Hemali Mehta
I-Chen Liu
Jinesh Gandhi
Pei-Ren Tsai

2. Health Condition
G.20 Parkinson’s Disease
Pattern 5A: Primary Prevention/ Risk
Reduction for the loss of balance and Falling

3. Impairments
Posture
Increased thoracic kyphosis and decreased
lumbar lordosis
Decreased ROM
B Hip Extension (-10) and knee extension(-5)
and ankle DF (0)
Decreased Strength
B Hip Abductors (3/5), Hip extensors (3/5), hip
flexors (4/5) and Ankle PF (3/5)

4. Impairments
Impaired Gait
decreased step length and shuffling gait pattern
Impaired Balance
TUG: 35 seconds
Berg: 40/56
Impaired Motor control
difficulty in initiation, freezing episodes
R hand resting tremor, R Bradykinesia

5. Activity Limitation
Community walking
ADLs
Driving
Lifting objects for grocery shopping
Baby sitting

6. Participation Restriction
Role as a Spouse/ Husband
Role as an independent Individual
Role as an grandparent/babysitter

7. Contextual Factors
Personal Factors
Age, good health with no co-morbidities,
medication for Parkinson’s (senimet), History of
frequently near fall
Environmental
Family support (wife to help him), Home
environment

8. Impairments Activity Limitation Participation
Impairer Posture
Spouse /
Husband
Independent
Individual
Grandpa /
Baby sitter
Community
walking
ADLs
Driving
Lifting Objects
Baby sitting
Decreased ROM
Decreased
Strength
Impaired Gait
Impaired
Balance
Impaired Motor
Control

9. Goals
1. The patient will improve muscle strength of
hip extensors, abductors from grade 3 to 4,
improve the BBS 5 points or more, to restrict
nearly fall situation less than 3 times / week
within 6 weeks
2. The client will demonstrate the ability to walk
at least 40 ft without freezing 50% of the
time within 6 weeks

10. Intervention
Balance Training: Stepping Ex
Direction: front and side
Feedback: KR for 66% of time(i.e. 3rd trial w/o
feedback)
HEP: 5reps in each direction x 1 set, 2time/day
(Baseline: The patient performed 6-7 reps for each
directions)

11. Repetitive step training with preparatory signals
improves stability limits in Parkinson’s patients,J
Rehabil Med 2012; 44: 944–949
Studies effects of volitional step training on
LOS, posture and gait.
RCT with control and experimental groups
Improvement in reaction time, movement
velocity and LOS = improvement in balance
3 times/week, 1 hour sessions for 4 weeks

12. Intervention
Gait training
Cues: External Auditory-Metronome
Feedback: Bandwidth
HEP: Walk 10 ft more than usual, self cues

13. Cueing training in home improves gait related
mobility in Parkinson’s disease: RESCUE trial, J
Neurol Neurosurg Psychiatry 2007;78:134–14
Randomized Crossover trial.
Cues given in a home based therapeutic
intervention
Cues; self selected ( auditory, visual or
somatosensory) given at patients preferred
frequency
3 times/week, 30 minutes, 3 weeks
Improvements in gait speed and step
length, tandem and one leg standing and
reduction of freezing by 5.5%

14. Motor Planning and
Learning
Motor Planning
Basal Ganglia: sensory integration
Central motor drive: APAs
Motor learning:
Procedural/Nonprocedural
REF: Evidence for motor learning in Parkinson's disease:Acquisition,
automaticity and retention of cued gait performance after training with
external rhythmical cues

15. Cueing? Dual Task?
Cueing: cues V.S. no cues?
In short term, change in gait parameters are
better with no cueing
In long term, there are significant changes in
gait parameters with auditory cues(retention)
Dual Task:
Research has shown that dual task increase
retention of PD
REF: Evidence for motor learning in Parkinson's
disease:Acquisition, automaticity and retention of cued gait performance after
training with external rhythmical cues

16. Novel Approach
Exercise Principle
1. Specificity
2. Progressive Overload
3. Varied Practice
Stage of Application?
REF: A novel conceptual framework for balance training in Parkinson’s
disease: a study protocol for randomized control trial.Conradsson et al. BMC
Neurology 2012