Clinical Correlation for PT

GENERAL INORMATION

Patient`s Name: S.E

Age: 66 years old
Sex: Male
Address: 0061 McArthur H-way, Tuktukan, Guiguinto, Bulacan
Civil Status: Married
Ethnicity: Hispanic-Filipino
Handedness: Left-handed
Occupation: Accountant
Referring Unit: MDH Neurological Department
Rehab MD: Dr. E.M
Date of Consultation:January 23, 2020
Date of Referral: January 28, 2020
Date of IE: January 29, 2020
Dx: Moderate Stage Idiopathic Parkinson`s Disease
Height: 1.79 m
Weight: 90 kg
BMI: Weight/Height² (90 kg/1.79²m = 28.125kg/m²)

SUBJECTIVE INFORMATION

C/C: “Noong nakaraang dalawang taon, napansin ko na parang

nangangatog yung kaliwang kamay ko pagka di ginagalaw. Di ko
naman masyadong pinansin noon hanggang sa nakasanayan ko
nang ganoon yung kamay ko. Tapos nitong nakaraang taon,
napansin ko pati yung kanang kamay ko ganoon na rin. Tapos
bukod doon, napansin ng asawa ko na parang bumagal ako
maglakad atsaka napansin niya rin na pag ako raw ay naglalakad
lakad sa bahay, madalas daw akong huminto ng walang dahilan.
Tapos 4 months ago, dalawang beses na akong nabubuwal at
madalas din akong mahilo pagkaraan ko uminom ng gamot buti na
nga lang eh gasgas lang inaabot sa tuhod kaya lagi nakaantabay sa
akin si misis di tuloy ako masyadong naglalakad-lakad dito sa
opisina ko sa bahay. Tapos nung nakaraang linggo, habang
naglalakad eh nabuwal nanaman ako kaya pinilit na ako ng asawa
ko na magpatingin.“

PT Translation: Pt c/o bilateral resting hand tremor, shuffling gate, freezing episodes
and high tendency of falls which contributes to difficulty in
ambulation.

Pt`s Goal: To be able to improve problems with balance and his shuffling gait
to ambulate within the house safely, to fix his resting hand tremor on
his (B) UE and to help him ambulate inside the house safely.

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 HPI:
This is a case of patient S.E a 66 yr. old male. He is an accountant for more than 20
years.
Present condition started ~2 years PTIE, when he observed that his(L) UE has resting hand
tremor.
~1 year PTIE, his resting hand tremor on the (L) UE progressed to a bilateral (UE) affectation
and the pt has started manifesting shuffling gait and freezing episodes from time to time.
~4 months PTIE, the pt fell twice after taking his medications and resulted to
bruises to the knee which made it difficult for him to ambulate within his house and
as a precautionary measure, his wife is always observing him.
~1 week PTIE, the pt fell again which prompted him and his wife to consult
medical attention in Meycauayan Doctors Hospital (MDH). The physician referred him
to undergo an ancillary procedure:MRI and told him to come back immediately after
receiving the result.
~ 2 days PTIE, the pt returned to MDH and the physician referred him to the
neurological department of the hospital for further evaluation. Dr E.M then diagnosed
the patient with Moderate Stage Idiopathic PD. Dr E.M told the patient that he has
probable PD and it is in the moderate stage already due to the manifestations. Dr E.M
referred the patient to the physical therapy department for falls risk assessment,
maintain his functional status, his concerns regarding the condition and for further
evaluation aside from that, he was also referred to take Sinemets to aid him with his
freezing episodes.

Past Medical Hx:

➢ (+) DM (Type 2) ~ controlled since 2018
➢ (+) HTN ~ controlled since 2016
➢ (+) Fall ~ 4 mos & ~1 week PTIE
➢ (-) Vestibular Disorders (e.g vertigo, nystagmus)
➢ (-) Trauma
➢ (-) Psychiatric History
➢ (-) Infections (e.g measles virus, herpes simplex virus type 1&2 ,
cytomegalovirs)
➢ (+) Fall ~ 4 mos & ~1 week PTIE
➢ (-) Asthma
➢ (-) CVA
➢ (-) CVD
➢ (-) OA
➢ (-) Hyperthyroidism

Family Hx:
Maternal Paternal

HTN (+) (+)

DM (Type 2) (+) (-)

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OA (+) (-)

PD (-) (-)

CVD (-) (-)

Others:

Personal/Social History:
Personality: Type B Personality
Lifestyle: Sedentary Lifestyle
(-) Smoking Hx:
(+) Alcohol Hx/Dosage:

Work Situation:
➢ Pt works from 8am - 7pm everyday (Monday - Saturday)
Sig: Unbalanced circadian timing system results to undesirable
health consequences (Jehan et al., 2017)
➢ Pt is home-based because he has his own office
➢ He works as a Tax accountant with many clients which he meets
via online platforms
➢ Pt. Office is beside their bedroom

Home Situation:
➢ Home: Bungalow which is wide and is well-lit, lives with
spouse, 1 grand child and a dog.
Sig: Positive attitudes and reinforcements from loved ones often
help the individual work towards recovery. (Nedwig, 2017)
❖ Type of flooring: Hardwood Flooring with floor mats
❖ Lighting: Fluorescent Lights
❖ Door Width: 30 in.
❖ Type of doorknob: lever
❖ Type of faucet handle: lever
❖ Distance of Office ↔ Bedroom: ~12 steps
❖ Distance of Office ↔ Bathroom: ~14 steps
❖ Distance of Office ↔ Kitchen: ~31 steps
❖ Distance of Office ↔ Living Room: ~26 steps
❖ Distance of Office ↔ Main Door: ~35 steps
❖ Distance of Main Door ↔ Gate: ~21 steps

Ancillary Procedure/s:
Date Test/Procedure Result
January 24,2020 MRI Scan Reduced uptake of the
Substansia Nigra

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Present Medication:
Medicine Dosage Frequency Indication
Metformin 500 mg b.i.d lowers blood sugar
levels
Accupril (ACE 25 mg OD Increases the
Inhibitor) amount of blood
pumps and lowers
blood pressure due
to the widening of
blood vessels.
Sinemet (formulation 12.5mg/50mg prn Used to treat
of Carbidopa and (1:4 ratio of Carbidopa symptoms of
Levadopa) and Levadopa) Parkinson`s disease
and other
parkinson-like
symptoms for a
certain amount of
time.

OBJECTIVE INFORMATION
A. Vital Signs
Before During After
Temperature Afebrile Afebrile Afebrile
RR 17 cpm 19 cpm 20 cpm
HR 80 bpm 85 bpm 92 bpm
BP 120/80 mmHg 130/80 mmHg 120/80 mmHg
Findings: Pt`s BP increased beyond normal limits during and after treatment.
Significance: For baseline purposes, treatment safety measures.

B. Ocular Inspection
➢ Pt is ambulatory s AD
➢ Pt is Endomorph
➢ Pt has slight masked face (hypomimia)
➢ (+) Pin Rolling on (B) UE
➢ (+) Postural Deviation: Simian Posture
➢ (+) Gait Deviation: Shuffling gate
➢ (-) Atrophy
➢ (-) Line Attachments
➢ (-) Discolorations
➢ (-) Bruises
➢ (-) Sialorrhea

C. Palpation
➢ Pt is normothermic on all exposed body parts
➢ Pt is hypertonic on (B) UE
➢ (-) Subluxation
➢ (-) Tenderness
➢ (-) Edema

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D. Neurological Evaluation:
1. Level of Consciousness: A/C/C x3
2. Superficial Sensory Testing:
STD used: cotton for light touch (LT), pinprick for pain and thumb for pressure
Findings:
Pt has 25% sensory deficit on (L.) ant and post. FA, wrist & hand as to
LT
Pt has 30% sensory deficit as to LT on (B) LE
Pt has 20% sensory deficit as to P on (B) UE
Pt has 40% sensory deficit as to P on (B) LE
Pt has 20% sensory deficit as to Pr (B) UE
Pt has 30% sensory deficit as to Pr (B) LE
3. Deep Somatic:
No. of stimulus
SENSATION MODALITIES AREA POSITION
identified / trials
R arm, forearm,
8/10
hand During initial wrist
L arm, forearm, flexion
7/10
hand
KINESTHESIA NONE
R thigh, leg,
6/10
foot
Mid-dorsiflexion
L thigh, leg,
6/10
foot
R arm, forearm,
7/10
hand During initial wrist
L arm, forearm, flexion
6/10
hand
PROPRIOCEPTION NONE
R thigh, leg,
7/10
foot
Mid-dorsiflexion
L thigh, leg,
7/10
foot
R arm, forearm,
10/10
hand
L arm, forearm,
10/10
hand
VIBRATION TUNING FORK
R thigh, leg,
10/10
foot
L thigh, leg,
10/10
foot

Findings: Pt has decreased kinesthesia on (B)UE & LE

Pt has decreased proprioception on (B) UE & LE

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4. Deep Tendon Reflex
+ +
L R
+ +

+++ +++

Findings: Hyperreflexive on B (UE)

Sig: To check intact reflex arc

5. Associated Reflex:

Associated Reflex Response Findings:

Glabellar Reflex
Palmomental Reflex
(+) persistent blinking (+) Myerson`s Sign
when the glabellar area is
tapped.
(+) The skin over the chin (+) Palmomental Reflex
wrinkles, and the mouth
elevates slightly after a
disagreeable stimulus is
drawn from the thenar
eminence at the wrist up
to the base of the thumb

6. Motor Control:
a. Tone Assessment
➢ Head Dropping-Test
1. The examiner placed one hand under the pt`s occiput and with the other hand briskly raises
the head.
2. The pt then allows the head to drop on the palm of the examiner`s other hand.
Findings: The pt`s head falls slowly, gently and almost hesitantly
Sig: (+) striatal disease

➢ Pendulousness of the Arms (Wartenburg`s Pendulum Test)

1. Pt stands, relaxed with the arms hanging freely.
2. The examiner extends both arms to the same horizontal level and then, releases them.
3. If the patient is completely relaxed or cooperative, there will normally be a swinging of the
arms that progressively diminishes in range and usually disappears after six or seven
oscillations.
Findings: there is a decrease in swinging time, but usually no qualitative change in the
reponse.
Sig: (+) Extrapyramidal Rigidity

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b. Balance
➢ TUG Test
1. Pt seated comfortably in a firm chair with arms and back resting against the chair
2. Instructed to rise, stand momentarily, and then walk 3m (10 ft) toward a wall at normal
walking speed, turn s touching the wall, return to chair, turn, and sit down.
* a practiced trial was done before the timed trial.

Findings: Pt`s score is 13.25 seconds

Sig: The tug cut off score for patients with PD ranges from 8-11.5 seconds
which means that the pt has high risk of fall

➢ Single Limb Stance Test

1. The pt is instructed to stand on one leg (of the side they chose) without support of the UE
or bracing of the unweighted leg against the stance leg.
2. The pt begins with the eyes open, practicing once on each side with his gaze fixed straight
ahead.
3. The pt is then instructed to close his eyes and maintain balance for up to 30 seconds.
4. The number of seconds that the pt is able to maintain this position is recorded.
Note: The pt’s (L) foot touches the floor twice before the recorded trial (eyes-closed)
Findings: (Eyes-opened) -- 15.5 seconds
Sig: The cut off score for ages 60-69 yrs old ranges from 8.6 seconds - 22.5 seconds
which means that the pt has less probability of falling with the eyes open.
Findings: (Eyes-closed) -- 6 seconds
Sig: The cut off score for ages 60-69 yrs old ranges from 8.6 seconds - 10.2 seconds
which means that the pt has high chances of falling when the eyes are closed

c. Coordination
Left Right
4 Finger to Nose 4
4 Finger to PT`s finger 4
4 Finger to Finger 4
3 Alternate nose to finger 4
2 Finger opposition 4
4 Mass grasp 4
3 Pronation/Supination 4
2 Rebound test 4
3 Tapping (hand) 4
4 Tapping (foot) 4
3 Pointing & Pass Pointing 3
3 Alternate heel to knee; heel to toe 4
4 Toe to PT`s finger 4
4 Heel on shin 4
4 Drawing a circle 4
3 Fixation or Position holding 4

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Findings: Pt has normal performance on the (R) UE ; mild to moderate performance
on (B) LE and (L) UE.
Note: Pt has difficulty in initiating activities with (L) UE such as: finger opposition
& pronation/ supination.
Sig: Pt can have mild difficulty in eliciting uni./bilat. act. With the use of (L) UE and
(B) LE.
d. Cranial Nerve Testing
all cranial nerves are tested and are intact except for:
Nerve Procedure Findings
I. Olfactory Pt. Identify 3 different Pt. was not able to identify
odorants (e.g: coffee, the difference between
vanilla and vinegar) coffee and vanilla
II. Oculomotor Pt must be able to follow Pt. was able to follow PT’s
the PT`s finger (H-test) for finger
primary gaze
VII. Facial Pt is asked to raise the Pt was not able to
eyebrow, show teeth, close accomplish all of the task
eyes tightly, and puff his given
cheeks.
IX. Glossopharyngeal Pt is asked to identify Pt. Was not able to
(sensory) different taste (sweet, identify sour and bitter
salty, bitter and sour) taste
IX. Glossopharyngeal & Pt is asked to say “ah” The palate rose
X. Vagus symmetrically and there is
(motor) a little nasal air escape.
Findings: CN1 affectation - Anosmia, CN7 affectation - Hypomimia & CN9
affectation - Ageusia
Sig: Anosmia is a common nonmotor feature of PD, Hypomimia is a common motor
feature of PD and Ageusia is not common but also a nonmotor feature of PD
E. Range of Motion
All joints of (B) UE/LE are WNL, pain free, actively & passively done except for:

Motion Active Passive Difference End feel

(R) Trunk Rotation 0 - 15˚ 0 - 25˚ (10˚ - 0˚) Pathologic Firm
Normal Value: 0-25˚
(L) Trunk Rotation 0 - 15˚ 0 - 25˚ (10˚ - 0˚) Pathologic Firm
Normal Value: 0-25˚
(R) Shoulder Flexion 0 - 165˚ 0 - 170˚ (15˚ - 10˚) Pathologic Firm
Normal Value: 0-180˚
(L)Shoulder Flexion 0 - 160˚ 0 - 165˚ (20˚ - 15˚) Pathologic Firm
Normal Value: 0-180˚
(R) Shoulder Abduction 0 - 165˚ 0 - 170˚ (15˚ - 10˚) Pathologic Firm
Normal Value: 0-180˚
(L) Shoulder Abduction 0 - 160˚ 0 - 170˚ (20˚ - 10˚) Pathologic Firm
Normal Value: 0-180˚
(R) Hip Extension 0 - 20˚ 0 - 30˚ (10˚ - 0˚) Pathologic Firm
Normal Value: 0-30˚
(L) Hip Extension 0 - 15˚ 0 - 30˚ (15˚ - 0˚) Pathologic Firm
Normal Value: 0-30˚
(R) Ankle DF 0 - 15˚ 0 - 10˚ (5˚ - 10˚) Pathologic Firm
Normal Value: 0-20˚
(L) Ankle DF 0 - 10˚ 0 - 10˚ (10˚ - 10˚) Pathologic Firm
Normal Value: 0-20˚
Cervical Flexion 0 - 30˚ 0 - 35˚ (15˚ - 10˚) Pathologic Firm
Normal Value: 0-45˚
Findings:
AROM: Pt has LOM in bilateral shoulder flexion and abduction L > R
Pt has LOM in bilateral trunk rotation
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 Pt has LOM in bilateral hip extension, bilateral dorsiflexion L > R
PROM: Pt has LOM in bilateral shoulder flexion and abduction L > R
Pt has LOM in bilateral dorsiflexion L > R
Note: Some limits due to mild rigidity (cogwheel)
Sig: Pt may have difficulty performing ADL.
F. Functional Muscle Testing (FMT)
Starting Position Action Functional Test Grade
Supine Lying Lift head keeping 6-8 reps : Functional Functionally Poor
3-5 reps: Functionally fair
chin tucked in 1-2 reps: Functionally
(neck flexion) poor
0 rep: Nonfunctional
Standing Lift foot onto 5-6 reps: Functional Functionally Poor
3-4 reps: Functionally fair
20-cm step and 1-2 reps: Functionally
return (hip flexion- poor
hip extension) 0 rep: Nonfunctional
Standing Sit in chair and 5-6 reps: Functional Functionally Poor
3-4 reps: Functionally fair
return to standing 1-2 reps: Functionally
(hip extension- hip poor
flexion) 0 rep: Nonfunctional
Standing Squat 20˚ to 30˚ 5-6 reps: Functional Functionally Poor
3-4 reps: Functionally Fair
1-2 reps: Functionally
Poor
0 rep: Nonfunctional

Findings: Pt has significant decrease in mm strength on (B) , neck flexors, hip flexors,
hip extensors and knee flexors.
Significance: neck flexors weakness results to forward head posture and weakness of
the hip flexors, hip extensors and knee flexors will be a hindrance for ADL.

G. Functional Mobility
Bed Mobility:
Rolls to the side: dependent
Bridging: independent
Transitional Movement:
Rolls to (R): dependent
Rolls to (L): dependent
Scoots up in bed: dependent
Supine-to-sit: dependent
Sit-to-supine: independent
Sit-to-stand: independent with supervision/ minimum assistance
Standing: Independent but with supervision/ minimum assistance
Eating: independent
Bathing: independent but with supervision
Dressing: independent but with supervision
Sig: Functional mobility is essential for a person to complete every day task.

H. Gait Analysis
Pt. ambulates in level surface s AD. Pt. manifests shuffling gait C ↓ arm swing,
insufficient hip extension and flexion, ankle dorsiflexion and poor hip positioning
during stance phase on (B) LE. ↓ stride and step length.
Sig: The pt would have difficulty in ambulation which is essential for a person to complete

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ADLs.
I. Postural Analysis
The patient is assessed in a comfortable sitting position with all bony landmarks
are symmetrical level except for:

Landmark Anterior Lateral

Head Forward translation of the
head and face because of the
neck
Neck Upper cervical vertebrae is There is a forward translation
hyper-extended of the cervical vertebra
Shoulder Rounded shoulders

J. Self-Reported Outcome Measures:

1. Parkinson`s Disease Questionnaire (PDQ-39): 38/156 = 24%
Findings: Most affected areas: mobility and activity level
2. Patient Health Questionnaire (PHQ-9): 3/27 = 11%
Findings: <4 suggests minimal depression which may not require treatment

ASSESSMENT
A. PT Diagnosis: Impaired motor function and sensory integrity associated with
progressive disorders of the CNS.
B. PT Impression: Pt is a 66-year-old male c a medical diagnosis of Moderate Stage
Idiopathic Parkinson`s Disease further defined by manifestations of the following
signs and symptoms: Simian posture, bradykinesia as manifested by: hypomimia
(masked face), ageusia, anosmia, shuffling gait and resting hand tremor on the (B) UE.
He also has sensory loss on some parts of the body secondary to ageing and diabetic
neuropathy. Pt is normothermic, hypertonic on (B) UE and has no pathological
reflexes but is positive in Myerson`s Sign and Palmomental reflex-- an associated
reflex. Pt is (+) striatal disease during the Head dropping test, (+) extrapyramidal
rigidity during the Pendulousness of the Arms testing, Pt scored 13.25 seconds in the
TUG test to test his balance and this implies that he is at high risk of falling and
during the single limb stance (eyes opened) 15.5 secs and (eyes closed) 6 seconds
which implies that he has higher risk of falling when he has no vision.The PT also
noted that the pt has difficulties in initiating activities with the use of his (L) UE. Pt
has LOM in cervical flexion, bilateral shoulder flexion and abduction L>R, bilateral
trunk rotation, bilateral hip extension and dorsiflexion L>R some of these limits are
due to mild rigidity (cogwheel). Pt has significant decrease in mm strength on (B)
neck flexors, hip flexors, hip extensors and knee flexors. According to the gait
analysis, the patient has ↓arm swing, ↓stride and step length and has difficulty
positioning during stance phase. According to the self-reported outcome done by the
patient, 1. Parkinson`s Disease Questionnaire (PDQ-39): 38/156 which implies that
mobility and activity levels are the most affected area in the patient`s life and on the
other hand, the 2. Patient Health Questionnaire (PHQ-9): 3/27 implies that the patient
has minimal depression which may not require treatment.

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C. Prognosis/ Rehabilitation Potential
Pt has poor prognosis considering that the pt. has the following factors:
1. The Parkinson`s disease is a progressive disorder. He is only at the
mild/moderate-stage which implies that it will probably worsen.
2. The patient has DM Type 2 and hypertension which might add to issues and
complications the patient will be experiencing in the future.
3. The pt is already 66 years old which makes it difficult for him to comply to the
instructions during treatments.
(+) Factors:
1. He has a supportive family system.
2. He has a type B personality, non smoker and occasional drinker which reduces his
risks in having additional complications with his health.

D. Problem List
1. LOM in cervical flexors, (B) shoulder flexors and abductors; trunk rotators; (B)
hip extensors; and (B) dorsiflexors
2. Muscle weakness in (B) back extensors, neck flexors, (B) hip extensors and flexors,
and (B) knee flexors
3. Postural deviation: Simian Posture
4. Gait Deviation: Shuffling Gait
5. Risk of fall due to impaired balance mobility

E. Long Term Goals

Preventive
✓ Pt. will be educated to be able to understand and recognize existing condition, it’s
progression and associated complications in the future.

Participative
✓ Pt. will still be able to comply with his job as a home-based accountant.

Rehabilitative
✓ Pt. will be able to ambulate inside the house safely.

F. Short Term Goals

1. Pt. will achieve an increase of 5-10 degrees of increments towards cervical flexion,
shoulder flexion and abduction; hip extension; dorsiflexion and trunk rotation
ROM as to assist in bed mobility and overhead tasks within 4 treatment sessions.
2. Pt. will achieve an increase back extensors; (B) hip extensors and flexor; and knee
flexors muscle strength from 3/5 to 4/5 as manifested by ability to ambulate
independently within 5-8 treatment sessions.
3. Pt. will increase neck flexors muscle strength from 2/5 to 3/5 as manifested by
being able to dress independently.
4. Pt. will be able to improve posture as manifested by standing up straight within 4-6
treatment sessions.
5. Pt. will be able to ambulate within the house with minimal assistance with 3-4
sessions.
6. Pt. will improve balance and coordination to perform walking on uneven surface,
turning skill, and transferring movements within 5- 8 treatment session

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PLAN

PRESCRIBED PT MANAGEMENT
1. AROME on (B) shoulder flexor and abductors; (B) hip extensors; (B) dorsiflexors; and trunk
extensors x 10 reps x 2-3 sets
2. Bilateral D2 Flexion x 10 reps x 2-3 sets
3. Relaxation exercises (PNF) x 10 reps x 2-3 sets
4. Chest stretch x 7SH x 10 reps x 2-3 sets
5. Pole walking technique for gait
6. Stationary bike exercise x 20 mins x twice a week
7. Kitchen sink exercises x 4 sets as tolerated
8. Grade IV: Rhythmic Oscillating mobilization on (B) UE for 60 minutes

SUGGESTED PT MANAGEMENT
✓ Refer pt to an occupational therapist to address his mild hand resting tremor.

HOME/ WARD INSTRUCTIONS

✓ Educate the pt`s family about the condition, assist pt in home exercises and motivate the
patient to have an active lifestyle.
✓ Observe proper posture and body mechanics.
✓ Family members must have a phone number of the pt’s physician to be able to ask
questions when problems like injury from a fall or possible symptoms like memory loss
occur.
✓ Put most used things in one place for easy reach and avoid extra trips.
✓ Put no-slip tape and handrails in the tub to prevent falls.

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