Back Pain in a Person with Parkinson’s Disease

1. Back Pain in a Person withParkinson’s Disease Sharna Garrett DPT, ATC Performance Physical Therapy Hockessin, DE

2. Background info • February 2006 • 66 y/o male • CC: back pain; also has pain in bilateral LEs What else do you want to know?

3. Subjective • Worse? • Quick movements, Sit→Stand (8/10) • Better? • Sitting (1/10) • Numbness/Tingling? • None

4. Subjective • Weakness? • Both Legs, causes falls* • Bowel/Bladder Sx? • None • Occupation • Retired Organic Chemist *more about that later

5. Medical History • Parkinson’s Disease • Diagnosed in 1991 • Medications: Amantadine, Mirapex, Sinemet (also supplements)

6. Symptoms of PD • Resting tremor • Bradykinesia • Rigidity of limbs • Postural dysfunction/instability • Low voice volume (dysarthria) • Masked face (decreased facial expression) • Small handwriting (micrographia)

7. Medical History • Hoehn and Yahr Staging • Stage 1 • Signs and symptoms on one side only and mild • Symptoms inconvenient but not disabling • Usually presents with tremor of one limb • Friends have noticed changes in posture, locomotion and facial expression • Stage 2 • Symptoms are bilateral • Minimal disability • Posture and gait affected

8. Medical History • Stage 3 • Significant slowing of body movements • Early impairment of equilibrium on walking or standing • Stage 4 • Severe symptoms • Rigidity and bradykinesia • No longer able to live alone • Tremor may be less than earlier stages • Stage 5 • Cannot stand or walk • Requires constant nursing care

9. Social Hx • Lives with wife • Ranch style home, with 1 step to enter • 14 steps to basement (pt goes down several times per week) • Ramps at outside doors, shower chair, toilet seat riser

10. MRI Report • Multi-level advanced degenerative changes with scoliosis causes multi-level bilateral neuroforaminal impingement and moderate central canal stenosis. (T11-S1) • Abutment of the cord at T11/T12 and T12/L1 levels What do you want to test? What impairments do you expect to see?

11. Physical Exam • Observations • Gait • ROM • Full ROM LEs and Lumbar spine (Muscular rigidity bilateral LE) • Increased right low back and R ant thigh pain with flexion, extension, and right SB

12. Lower Quarter Screen • Strength (Bilateral) • Hip flex 4/5 Knee flex 3+/5 • Knee ext 4/5 PF NT • DF 5/5 • Reflexes • 1+ bilateral patellar and achilles • Dermatome Screen – Normal (Light Touch)

13. Special Tests • SI joint tests → Negative • SLR → Negative • Sitting Root/Slump → Negative • FABER → Negative

14. Impariments Pain ↓ flexibility Weakness ↓ endurance Gait dysfunction *PD symptoms Functional Limitations Falls Uses walker Limited use of stairs Unable to sit/stand without using UEs Needs assistance with mobility (especially after falling) Nagi Disablement Model

15. Nagi Disablement Model • Disability/Handicap • Home most of the day • Limited time in the community • Needs to schedule appts in the morning only • Must have caregiver at all times

16. Plan • Pelvic Traction • Sidelying opening mobs • Therapeutic Exercise

17. Outcomes • After 7 treatment sessions • Back pain persists • LE pain worsens • Using wheelchair most of the day • Loss of bowel and bladder control Now what???

18. The New Plan • Seen by PCP → would like Neuro eval • Patient cancelled remaining PT visits • Neurosurgeon appt in 3 weeks

19. Almost Two Months Later… • Patient called to say lumbar decompression surgery scheduled for 1 week (this is 3 months after his last PT visit). • To continue PT at six weeks post-op

20. Six Weeks Later… • Patient is 4 ½ weeks post-op (June 2006) • Multi-Level Decompression/Fusion T10-Sacrum • New Rx: Strengthening, Coordination, Balance, GT • CC: ↓ leg strength, ↓ balance. • Occasional LBP, but no LE pain

21. Six Weeks Later…

22. Physical Exam • Strength (Before Surgery) • Hip flex 4/5 Knee flex 3+/5 • Knee ext 4/5 PF NT • DF 5/5 • Strength (After Surgery) • Hip flex 5/5 Knee flex NT • Knee ext 4+/5 PF 5/5 • DF 5/5 Hip abd 4+/5

23. Physical Exam • Reflexes (Before Surgery) • 1+ bilateral patellar and achilles • Reflexes (After Surgery) • 1+ bilateral patellar • 2+ bilateral achilles

24. Physical Exam • Static Balance • SLS with UE support <5 seconds • Tandem stance with eyes open 10 seconds • Tandem stance with eyes closed 4 seconds

25. Interventions • Therapeutic Exercise • Cardio Endurance (Stationary Bike) • Quad strength (Step up/down, Leg Press, Sit→Stand, Squat and pick up objects) • Balance (SLS on trampoline, Walk without rollator, Tandem walking, Turns) • Manual Stretching – Hamstrings, Hip Flexors

26. Interventions • 4 weeks after Initial Evaluation • Cancelled appt due to repeated falls • Neurologist: Continue PT, sx not due to PD progression Would you change the Physical Therapy plan?

27. New Plan (sort of) • New Emphasis on Transfers • Stand→Sit→Floor • Floor→Chair→Stand • Spent next two entire sessions practicing “just in case” techniques for falls

28. Outcomes • Improved Balance • SLS >10 seconds • Side step and retro walk 25ft without assistance • Improved Endurance • 5/5 LE strength

29. Outcomes • 2 weeks after D/C • Doing well with personal training • Falling less often, and is able to get up without several attempts • Slight change to medication (more Mirapex) • Using rollator only in public

30. QUESTIONS???

31. References • Fritz, Julie M, Delitto, Anthony, et al. “Lumbar Spinal Stenosis: A Review of Current Concepts in Evaluation, Management, and Outcome Measurements”. Arch Phys Med Rehab. Volume 79; June 1998. • Morris, Meg E. “Movement Disorders in People with Parkinson Disease: A Model for Physical Therapy”. Physical Therapy. Volume 80 (6); June 2000. • National Institutes of Health, National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov. • Parkinson’s Disease Foundation. www.pdf.org/aboutpd.

32. Thank You!!! • John and Carole Adams • Performance Physical Therapy, Hockessin, DE • Professor Stacie Larkin, University of Delaware Physical Therapy Department