The following case study illustrates some of the essential components of our movement disorders program at our institution for a patient with an APD.
MG is an 89-yr-old male who reported progressive worsening of gait and increased frequency of falls. He was started on L-dopa/carbidopa several months prior to admission by his primary neurologist, who suspected the patient had idiopathic PD. It was not clear that medication produced an improvement in function. His past medical history was significant for hypertension, coronary artery disease, chronic anemia, and a coronary artery bypass graft. Upon admission MG had no frank rigidity, but mild cogwheeling (left greater than right), and a mild to moderate symmetric bilateral action tremor. Functionally, the patient was able to walk with a minimal amount of assistance for distances of 100 ft with a rolling walker. His gait was characterized by an overall slow cadence, short step length, and a decreased base of support. On admission the patient was receiving one and a half tabs of L-dopa/carbidopa 25/100 three times a day. Given the patient's questionable response to L-dopa/carbidopa and his cardiovascular risk factors, the initial working diagnosis of the movement disorders team was APD.
Since MG was able to ambulate with a minimal amount of assistance, the patient was appropriate for functional testing using the TUG and 2-min walk. The supine to stand test was not appropriate since MG required assistance with bed mobility upon admission. After baseline measures were col-
Timed up and Go
Sinemet decreased to 0.5 lab TID
lected, L-dopa/carbidopa was tapered and discontinued because of the lack of evidence that it provided clear benefit. To ensure the patient had no negative effects from the medication taper, functional measures were collected after each medication change. Figures 2 and 3 describe performance on functional measures regarding medication changes.
At discharge the patient's functional measures were improved, about 10 s faster with the TUG and 26 ft farther with the 2-min walk from initial measures. The improvement in functional measures despite tapering L-dopa/carbidopa suggested that the improvement was the result of rehabilitation interventions. At discharge, the patient returned to assistive living.
This case illustrates several important contributions a movement disorders rehabilitation team can provide patients with atypical PD. Aside from the benefits of rehabilitation interventions, the team provided systematic objective measures of function to accurately conclude that MG did not benefit from pharmacological intervention.
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