Back Pain in a Person with Parkinson

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Back Pain in a Person withParkinsons Disease

• Sharna Garrett DPT, ATC
• Performance Physical Therapy
• Hockessin, DE

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Background info

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

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Subjective

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

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Subjective

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

5
Medical History

• Parkinsons Disease
• Diagnosed in 1991
• Medications Amantadine, Mirapex, Sinemet (also
  supplements)

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Symptoms of PD

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

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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

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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

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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

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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?

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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

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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)

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Special Tests

• SI joint tests ? Negative
• SLR ? Negative
• Sitting Root/Slump ? Negative
• FABER ? Negative

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Nagi Disablement Model

• 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)

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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

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Plan

• Pelvic Traction
• Sidelying opening mobs
• Therapeutic Exercise

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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???

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The New Plan

• Seen by PCP ? would like Neuro eval
• Patient cancelled remaining PT visits
• Neurosurgeon appt in 3 weeks

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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

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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

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Six Weeks Later
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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

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Physical Exam

• Reflexes (Before Surgery)
• 1 bilateral patellar and achilles
• Reflexes (After Surgery)
• 1 bilateral patellar
• 2 bilateral achilles

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Physical Exam

• Static Balance
• SLS with UE support lt5 seconds
• Tandem stance with eyes open 10 seconds
• Tandem stance with eyes closed 4 seconds

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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

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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?

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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

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Outcomes

• Improved Balance
• SLS gt10 seconds
• Side step and retro walk 25ft without assistance
• Improved Endurance
• 5/5 LE strength

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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

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QUESTIONS???
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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.
• Parkinsons Disease Foundation.
  www.pdf.org/aboutpd.

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Thank You!!!

• John and Carole Adams
• Performance Physical Therapy, Hockessin, DE
• Professor Stacie Larkin, University of Delaware
  Physical Therapy Department