Table 1
Examination Findings
| Examination | Findings |
|---|---|
| Manual muscle testing | >4/5 for all major muscle groups34 |
| Sensation | Light touch testing of upper and lower extremities intact |
| Finger-to-nose and heel on shin tests | Impaired non-equilibrium coordination23 |
| Vestibular | Smooth pursuits, saccades, and the VOR were examined.23 Difficulty was noted with an inability to vertically track above eye-level formal VOR testing was inconclusive, potentially due to anxiety associated with inducing dizziness through head turns |
| Functional observations | Poor proximal stability and body awareness with tasks were evident throughout the examination. As examples, he had difficulty with tandem gait and presented with a posterior lean and backward thrusting motion during sit to stand transitions and stair navigation. Difficulty with cervical and trunk disassociation were noted through observation of functional movements |
Table 2
Outcome Measure Results
| Outcome Measure | Pre-intervention | 1 Month | 2 Month | Score Interpretation (MDC and MCID) | Cut-off Scores for Risk of Falls |
|---|---|---|---|---|---|
| Berg Balance Scale | 44/56 | 53/56 | 56/56 | Exceeded the MDC of 5 points for those with Parkinsonism27 | 45/56 for community-dwelling adults with balance deficits24 |
| Functional Gait Assessment | 13/30 | 20/30 | 25/30 | Exceeded the MDC of 6 points for vestibular disorders25 | 15/30 for those with Parkinson’s disease28 |
| Five-Times-Sit-to-Stand | 18 seconds | 18.5 seconds | 12.9 seconds | Exceeded the MCID of 2.3 seconds for vestibular disorders26 | 16 seconds for those with Parkinson’s disease30 |
| 10 meter walk test (self-selected) | 1.13 m/s | 1.2 m/s | 1.3 m/s | Did not exceed the MDC of 0.18 m/s for those with Parkinsonism27 | N/A |
| 10 meter walk test (fast speed) | 1.6 m/s | Not Tested | 1.7 m/s | Did not exceed the MDC of 0.25 m/s for those with Parkinsonism27 | N/A |
Table 3
Intervention Progression
| Treatment Session No. | Gait Training | Functional Training | Balance Training | Strengthening | Miscellaneous |
|---|---|---|---|---|---|
| 1 | With a treadmill with verbal cues to increase heel strike, increase base of support, and for foot clearance | Sit to stand training1 | Multidirectional stepping | Scapular stabilization exercises in supine | Vestibulo-ocular reflex exercises (×1/×2)1 |
| 2 | With a treadmill with verbal cues to increase base of support, to increase arm swing, to clear the foot | Sit to stand training | Multidirectional stepping with verbal cues: for direction change and to colored dots on floor | Scapular stabilization exercises in supine | |
| 3 | With a treadmill with verbal cues to increase base of support, to increase arm swing, to clear the foot | Single limb stance with VMC (eyes open and eyes closed; on foam) | Discontinued scapular stabilization exercises due to lifting restriction; Four-way bilateral hip strengthening with resistance1 | ||
| 4 | Single limb stance on foam with trunk rotation | Four-way bilateral hip strengthening with resistance | Upright stationary bicycle with verbal cues for upright posture in an unsupported position Stepping lunges to raised steps with simultaneous trunk rotation | ||
| 5 | Overground1 with verbal cues for intermittent changes in direction (forward, backward, right, left) | Stepping over obstacles with changes of speeds | Four-way bilateral hip strengthening with resistance | ||
| 6 | Overground | Gait with obstacle training: stepping over and around objects, outdoor training, hills, ramps, and stairs with changing speeds | Single limb stance with VMC (eyes open and eyes closed; on foam; trunk rotation) | Weighted trunk rotation | |
| 7 | With a treadmill with incline with verbal cues for upright posture | Single limb stance on foam with addition of head turns to integrate visual exercises | Squat training with upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand | ||
| 8 | With a treadmill with incline with verbal cues for upright posture | Single limb stance on foam with addition of head turns and vestibulo-ocular reflex exercises | Squat training with upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand | Outcome measures assessed per outpatient rehabilitation regulations of every 30-day re-assessment | |
| 9 | Overground with resistance bands with verbal cues for upright posture and controlled movements | Gait and balance training through obstacle course training incorporating single limb stance, cross stepping, reactive stepping, changing speeds, and adding complex motor and cognitive tasks | Upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand while in quadruped and tall kneeling | Upright stationary bicycle with cues for upright posture | |
| 10 | Overground with resistance bands with verbal cues for upright posture and controlled movements | Stair training with the addition of complex motor tasks; verbal cues for body awareness and controlled movements | Gait and balance training through obstacle course training incorporating single limb stance, cross stepping, reactive stepping, changing speeds, and adding complex motor and cognitive tasks Static balance training that included visual complexity (background changes, head turns, eyes open and eyes closed) | Upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand while in quadruped and tall kneeling | |
| 11 | With the treadmill, retro-ambulation with verbal cues for “toe–heel” and leaning forward | Gait and balance training through obstacle course training incorporating single limb stance, cross stepping, reactive stepping, changing speeds, and adding complex motor and cognitive tasks Static balance training that included visual complexity (background changes, head turns, eyes open and eyes closed) | Upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand while in quadruped and tall kneeling | ||
| 12 | With the treadmill, retro-ambulation with verbal cues for “toe–heel” and leaning forward | Gait and balance training through obstacle course training incorporating single limb stance, cross stepping, reactive stepping, changing speeds, and adding complex motor and cognitive tasks Static balance training that included visual complexity (background changes, head turns, eyes open and eyes closed) | Upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand while in quadruped and tall kneeling | ||
| 13 | With the treadmill, retro-ambulation with verbal cues for “toe–heel” and leaning forward | Gait and balance training through obstacle course training incorporating single limb stance, cross stepping, reactive stepping, changing speeds, and adding complex motor and cognitive tasks Static balance training that included visual complexity (background changes, head turns, eyes open and eyes closed) | Upper extremity proprioceptive neuromuscular facilitation patterns (D1/D2) including visual tracking of the hand while in quadruped and tall kneeling | ||
| 14 | Outcome measure assessments for preparation of discharge from therapy Final patient education Final home program recommendations |
