Management of individuals with Parkinson's disease: rationale and case studies.

Management of Individuals with Parkinson's Disease: Rationale and Case Studies Parkinson's disease is a progressive central nervous system disease with predictable consequences. Patients with Parkinson's disease are easy to identify because of their stooped posture, shuffling gait, tremor, rigidity, slowness of movement, and poor balance. n1 Often, these patients are not treated by a physical therapist until they reach an advanced stage of the disease or have sustained a hip fracture secondary to a fall. In this article, we present a rationale for early physical therapy intervention for the patient with Parkinson's disease. This intervention is designed to minimize musculoskeletal limitations and postural deformity that accompany the disease, thereby improving the patient's capability for independent function as long as possible.

Our approach to intervention for the patient with Parkinson's disease is based on a model that identifies the relationship between the impairments of Parkinson's disease and the resulting disabilities (see accompanying article by Schenkman and Butler in this issue). n2 this model further differentiates among impairments that are a direct result of the CNS disease, those that occur indirectly because of chronic musculoskeletal alterations, and those that result from a composite of CNS and non-CNS impairments. Impairments with composite underlying causes are differentiated into those that affect automatic components of functional movement and those that affect voluntary components.

We demonstrate how the physical therapist can use this model to evaluate and interpret impairments and disabilities of the patient with Parkinson's disease. The therapist can develop a treatment program that can be analyzed and justified in terms of the pathology of Parkinson's disease and the resulting causal relationships between impairments and disabilities. We include two case studies to illustrate the apparent efficacy of early physical therapy intervention for individuals with Parkinson's disease.

Evaluation, Interpretation of

Findings, and Goal Setting

Problems of the patient with Parkinson's disease can be divided into four categories for evaluation purposes: 1) impairments that are a direct result of a disease; 2) impairments, such as musculoskeletal impairments, that occur in a system other than the nervous system; 3) impairments with composite underlying causes; and 4) disabilities (see the Appendix in the accompanying article by schenkman and Butler in this issue for definitions of the terms used in this article). Much of the physical therapy intervention is focused on problems that fit the categories of disabilities or on impairments that are composite effects of disease. Examples of typical problems that physical therapists treat include abnormalities of gait, difficulty with transfer, and difficulty with bed mobility. The physical therapist sets goals and designs treatments related to these and similar problems. The model that we have developed is designed to help the therapist interpret the causes of these problems. Thus, the evaluation should include assessment of disabilities and impairments that are direct, indirect, and composite effects of the lesion. These components of the evaluation are summarized in Table 1. The evaluation findings are used to interpret the physical theraphy problems. Table 2 provides some examples of the use of the model in making these interpretations.

Evaluation

Whenever possible, evaluation findings should be quantifiable although subjective descriptions are also important. For example, bed mobility and transfer disabilities can be evaluated in terms of the amount of time it takes a patient to move from a supine to a sitting position over the edge of a bed and then to a sitting position in a chair 6 ft * away. Impairments of the musculoskeletal system can be quantitated in terms of available active or passive range of motion. Quantifiable documentation of evaluation findings is important in monitoring a patient's deterioration or recovery over time. Descriptive documentation of the patient's patterns of movement may be helpful in recording how the patient accomplished a task.

Interpretation

After the evaluation is complete, the findings should be interpreted in an attempt to identify the relative importance of various factors that contribute to the patient's observed impairments and to determine which impairment contribute to each disability. The physical theraist is also faced with the task of deciding which impairments are a direct result of nervous system pathology and which result from subsequent musculoskeletal impairments. Schenkman and Butler have summarized the literature relating impairments to the pathology and disabilities of Parkinson's disease, and they have postulated relationships between direct and indirect effects of the disease (see accompanying article in this issue. The model developed by Schenkman and Butler can serve as a guide to help clinicians interpret findings from individual patients and then decide which problems can be addressed by physical therapy intervention and which cannot (see accompanying article in this issue). n2

Goal Setting

Once the evaluation findings have been interpreted, the physical therapist must decide which impairments are of greatest consequence for a given patient and which can be addressed by physical therapy intervention. The therapist uses this assessment in setting treatment goals. With a progressive disorder such as Parkinson's disease, goal setting should be tempered by an understanding of the progressive nature of the disease and by a realistic understanding of those aspects of the CNS disturbance that cannot be improved by physical intervention. For example, impairment of postural responses that results from lack of adequate trunk and pelvic mobility might be remediated by appropriate stretching and coordination exercises. Impairment of postural responses attributable to a direct loss of postural reaction mechanisms may not be as easily remediated by physical therapy intervention (see accompanying article by Schenkman and Butler in this issue). An appropriate goal, therefore, might be to improve postural reactions through improving musculoskeletal flexibility. Rigidity appears to result from CNS alterations creating an inability of the patient to relax. n3 It is unlikely that any peripheral physical therapy technique can produce a permanent state of relaxation of rigidity. Our clinical experience, however, suggests that a patient may learn to relax rigidity temporarily through self-relaxation techniques. The patient can then use these relaxation techniques to increase mobility or to retain normal ROM and postural alighment. That is, the patient can temporarily reduce the rigidity that is a direct effect of Parkinson's disease. More importantly, however, the patient can use this capability to achieve a more lasting increase in flexibility (eg, to reduce the indirect effect of the lesion on a long-term basis). An appropriate goal, therefore, might be to improve specific trunk and limb ROM. The method to reach the goal would be the use of relaxation techniques.

A few examples of problems, interpretations, and goals are presented in Table 2 to illustrate use of this method in the treatment of the patient with Parkinson's disease. The interpretations must be based on the complete evaluation findings. In the examples given, the interpretations are based on the expected impairments of the patient with Parkinson's disease (see accompanying article by Schenkman and Butler in this issue). [2] The goals in these examples are for four weeks of physical therapy.

In summary, the goals of physical therapy should be realistic. They should also be based on the patient's own goals as well as the therapist's knowledge of the disease process. It is important to identify which aspects of the disease are responsive to physical therapy intervention and which are not. When appropriate, goals should be as specific as possible and should be quantifiable. For example, functional goals might be based on the amount of time an individual requires to complete an activity or on the level of assistance (or independence) required. Goals related to the musculoskeletal system can be set in terms of the ROM of specific muscle groups that are shortened or stretched.

Treatment Approach

Following the evaluation, interpretation, and goal-setting approach developed in the preceding sections will enable the therapist to design a treatment approach that is responsive to the needs of the individual patient. Treatment of the individual with Parkinson's disease will be dependent on the specific deficits that predominate for that individual. Any treatment approach, however, should reflect a logical interpretation of pathology, impairments, and disabilities. In this article, we present a treatment approach that we have developed. This approach is intended to illustrate problem solving based on a knowledge of the interrelationship of pathology and impairments, combined with principles of kinesiology and biomechanics. The treatment guidelines we propose represent only one of the various treatment approaches that can be used in treating patients with Parkinson's disease.

We propose that the following progression for treatment can be used as a guide, both within treatment sessions and over time:

1. Relaxation

2. Breathing exercises

3. Passive muscle stretching and positioning

4. Active ROM and postural alignment

5. Weight shifting

6. Balance responses

7. Gait activities

8. Patient home exercises

This approach to treatment draws on techniques traditionally used to treat the patient with Parkinson's disease. The value of the model we have proposed is that it helps us to understand components of the patient's disability we affect with each technique. A general summary of our philosophy is that knowledge of the direct effect of the lesion (resulting in rigidity) is used to identify techniques most effective in reducing rigidity in order to preserve musculoskeletal mobility. We emphasize both musculoskeletal impairments related to the respiratory system and those related to the postural system. By alleviating musculoskeletal impairments, we provide the patient with a mechanical capability to improve automatic postural responses and willed movement.

Relaxation of Rigidity, Breathing,

and Muscle Stretching

Relaxation is used first to reduce rigidity and to increase flexibility. From a kinesiological perspective, it is equally important to relax the axial musculature and the limb musculature. From our clinical experience, we suggest the use of slow, rhythmic rotational motions, beginning with very small ROMs, as an effective means of achieving relaxation, particularly of the axial musculature. This approach is based on the concepts of Feldenkrais. [4] a variety of other techniques might also be used, including contract-relax proprioceptive neuromuscular facilitation techniques [5] and biofeedback. [6] With some individuals, it may be necessary to begin with passive rotation; however, from an interpretation of the neuroanatomic pathology of Parkinson's disease, we believe that it is important to progress to active techniques so that the patient can learn methods of self-relaxation. Drawing from concepts of Bobath [7] and Rood [8] and from general principles of biomechanics, we recommend that relaxation of muscle tone should begin in supported positions (such as supine and side-lying positions). The supported position allows the patient to achieve optimal relaxation with minimal effort to keep the body upright. As the patient becomes facile with self-relaxation, it is possible to progress to the more difficult sitting position or even to the standing position. Although few objective data are available, it appears that most normal movement requires rotation throughout the spine. Thus, when performing relaxation techniques, it is important to differentiate between segments of the body so that all segments are individually relaxed (ie, head-neck on thorax, thorax on pelvic complex, pelvic complex on thorax, shoulder complex on thorax, upper extremity on shoulder complex, lower extremity on pelvic complex). The exercise techniques proposed by Feldenkrais are specifically designed to relax specific segments of the spine. [4]

Breathing can be emphasized during all aspects of intervention. Rhythmic, relaxed breathing is an essential component, of the relaxation response. [9] As relaxation is achieved, relaxed rotation of the upper extremity and neck in the supine position may then be used to facilitate increased chest expansion. Deep breathing can then be incorporated with chest expansion to increase the patient's vital capacity. [4,10] The focus on breathing exercises early in the disease process is designed to prevent musculoskeletal limitations that might contribute to the high incidence of pulmonary complications in the patient with Parkinson's disease. [11,12]

Once the patient knows how to achiev self-relaxation of rigidity, we suggest that these techniques be directed toward increasing the available passive and active ROMs. Muscle stretching can often be performed by the patient at home, [10] both in combination with relaxation exercises and alone. Appropriate positioning can be a useful adjunct to passive muscle stretching exercises.

Increasing Active Mobility

As with the relaxation techniques, we recommend beginning active mobility in supported positions and progressing to unsupported positions. Again, we emphasize exercise to achieve mobility throughout each segment of the spine. We believe that it is particularly important to achieve mobility for adequate lumbopelvic extension, lateral flexion, and rotation and for pelvi-femoral extension and rotation because these motions appear, clinically, to be directly related to the balance response. The "pelvic-clock" exercises of Feldenkrais are valuable for this purpose. [4]

In the supine and side-lying positions, we focus therapy on total rotation (from the cervical region through the lumbar spine). In the sitting position, we focus on lumbar extension, lumbar lateral flexion, lumbo-thoracocervical lateral flexion for trunk "elongation," cervico-thoraco-lumbar rotation, and thoracic extension. Deep breathing is combined with thoracic extension exercises. The prone extension position can be used to increase lumbar extension, the quadruped-on-elbows position can be used to achieve thoracic extension, and the quadruped position can be used to increase lumbar extension.

In the standing position, we focus on lateral pelvic tilts. We emphasize the lumbar extension component of the anterior pelvic tilt, the hip extension component of the posterior pelvic tilt, and the lumbar lateral flexion and pelvifemoral components of the lateral tilt. These components of normal motion will be achieved more readily if adequate mobility of the lumbar spine is first achieved in the more supported positions. (When lumbar mobility is limited, attempts to increase it in the standing position are more likely to produce pelvifemoral motion than lumbopelvic motion.) Once lumbopelvic motion can be achieved, we emphasize weight shifting for unilateral weight bearing.

Weight Shifting and Balance

After musculoskeletal impairments have been addressed and the patient has adequate ROM for automatic movements, the therapist can focus on balance impairments. Balance activities should follow weight-shifting activities in each position. First, the patient should progress from weight shifts with lumbo-thoraco-cervical rotation and elongation to balance activities in the sitting position. Then, weight-shifting activities and rotation should be followed by balance activities in the standing position. Both self-induced and externally induced balance responses should be elicited. In self-induced responses, the patient displaces his or her own center of gravity outside the base of support by reaching upward and outward in various directions; the focus is on counterbalancing motions of the upper and lower extremities and on protective responses. In externally induced balance responses, the therapist gradually shifts the patient's center of gravity while eliciting normal righting responses. It is important for the patient to be able to respond effectively to both self-induced and externally induced displacements. Self-induced displacements occur any time the patient moves his or her center of gravity outside the base of support, such as in reaching, dressing, or most other functional activities. Externally induced displacements occur, for example, when the patient is jostled in a crowd, trips on an uneven pavement, or sustains other forces from the outside. Furthermore, both slow and fast balance reactions should be elicited and treated.

Function

Ultimately, a primary purpose of physical therapy intervention is to reduce disabilities by improving the patient's ability to function. Whenever possible, functional activities should be incorporated into mobility exercises. There is increasing evidence that exercise is most effective when it is task specific. [13] These findings might be especially important for the patient with Parkinson's disease in light of the impairments in motor planning and programming characteristic of the disease. A few examples are given, but any functional activity can be incorporated with all aspects of treatment. Rolling and moving from a supine to a sitting position can be combined with active trunk rotation exercises. Rising to a standing from to a sitting position can be incorporated into anterior pelvic-tilt exercises. Sitting down from a standing position can be incorporated into balance activities. Gait activities can be incorporated into standing balance and weight-shifting activities. It is important to focus on gait patterns used for both distance walking and the slower walking cadence used in many functional activities. In distance walking, the focus might be on trunk counter-rotation and lower extremity motions (eg, step length, heel-strike). During gait for functional activities (eg, dressing, bathing, cooking), the focus might be on weight shifting with more prolonged weight bearing in single-limb-supported positions. The gait pattern involved in distance walking represents a continuous state of dynamic stability with progression in a forward direction. n14 The gait pattern involved in functional activities appears to require an ability to execute a continuous, slower motion; controlled weight shifts; and changes in direction of movements. We were unable to find data related to requirements for walking during functional activities. Based on our observations and clinical experience, however, this type of walking appears to have different characteristics than the gait pattern required for forward ambulation. We suggest that these differences be reflected in treatment programs.

One of the most difficult problems appears to be that of improving the patient's ability to use automatic responses during willed functional movement. Clinical experience suggests that continuing repetition of a variety of balance activities may help the patient to regain appropriate postural responses. Similarly, repetition appears to improve functional movements. To data, no objective data exist regarding whether or to what extent normal motor planning and programming ability and balance can be restored through deliberate repetition. An increasing body of literature, however, emphasizes the importance of repetition for learning and skill acquisition. _[13] Out clinical experience indicates that patients do improve their ability to move appropriately in a complex environment, suggesting either that they become adept at compensating for their loss in planning and programming ability or that improvement is achieved in these abilities. As data become available, differentiating musculoskeletal from motor contributions to loss of automatic postural responses, it should become possible to investigate this problem further.

The Patient's Role in Treatment

Parkinson's disease is a chronic degenerative process. The therapsist should teach the patient home exercises as soon as possible, both to ensure ongoing effective intervention and to provide the patient with some control over the disease. Specific muscle stretching exercises can be performed at home and should include stretching of the trunk musculature as well as the limb musculature. For example, the patient can be taught home exercises to lumbo-thoraco-cervical extension, rotation, and lateral flexion. Hamstring and gastrocnemius muscle stretching are commonly required. [10] Other commonly required exercises are for hip extension, external rotation, and abduction; shoulder flexion, abduction, and external (medial) rotation; elbow extension; forearm supination; and hand and finger extension. An important aspect of the home exercise program is postural reeducation incorporating the acquired flexibility into appropriate postural alignment throughout the day. The degree to which a patient is able to maintain correct postural alignment may determine his or her ability to maintain normal flexibility and ROM. As the patient learns more appropriate patters of movement, other activities (eg, balance activities) can be added to the home exercise program. Once maximum therapeutic gains have been achieved, the patient will need to maintain those gains through self-exercise.

Summary of Treatment Approach

In summary, the physical therapy intervention approach we recommend consists of a logical progression of exercise techniques designed to teach the patient self-relaxation of rigidity, to maintain normal flexibility and ROM, and to restore normal automatic movement patterns through repetition. The extent to which this approach is successful may depend in part on the extent to which fixed deformity has already occurred. In general, we suggest that any success in maintaining flexibility and ROM should improve the patient's functional ability. Once a patient has completed an active physical therapy program, he or she should continue on a home exercise program designed to maintain flexibility, ROM, and quality of movement. Because Parkinson's disease is progressive, this exercise program should become a regular part of the individual's daily activities. Periodic reassessments by a physical therapist are essential so that the program can be modified as the disease progresses.

We present two case studies to illustrate the evaluation, interpretation, and treatment of individuals early in the course of Parkinson's disease. The first case study involved a man who was not receiving medication for the disease. The second involved a man who was receiving medication for the disease. Parkinsonian medications were constant for this individual throughout the period of invervention. Evaluations were performed at the same time relative to the use of medication so that observed changes would not reflect fluctuations that occurred as a result of timing of medication. The evaluation protocol used in these case studies is shown in the Appendix.

These two individuals were participants in a pilot study we performed prior to formal single-case design study of individuals with Parkinson's disease. We present these case studies to illustrate the application of interpretation of neuroanatomical pathololgy and impairments in designing a program for physical therapy management of individuals with that disease. (From our experiences with these two patients, we have further refined our evaluation and treatment protocols and are currently conducting a multiple case-study of individuals including several intervention and nonintervention periods. This work, which will be the subject of a future article, serves to investigate the efficacy of physical therapy intervention.)

Case Studies

Case 1

"TN" is a 67-year-old businessman diagnosed with Parkinson's disease in January 1987. The presenting signs that caused him to seek medical attention included slowing of all activities, impaired balance, and difficulty with functional movements such as rising from a chair and walking. Relevant prior medical history included angina since 1982 and cervical arthritis since 1972. In March 1987, TN was referred for physical therapy to determine whether appropriate exercise intervention would delay the necessity for pharmacologic intervention.

For this individual, bradykinesia presented the greatest difficulty and interfered with all aspects of his life. Our interpretation of the evaluation findings suggested that slowness of movement might have been a composite result of direct and indirect effects of the disease (see accompanying article by Schenkman and Butler in this issue). Direct nervous system pathology could have accounted for the patient's rigidity, decreased postural responses, decreased automatic movements such as trunk rotation and reciprocal arm swing for gait, slowness in functional movements, and "masked" face. These impairments could have contributed indirectly to the patient's musculosketal impairments including loss of soft tissue length and flexibility. The musculoskeletal impairments in turn may have contributed to his abnormal posture, decreased weight shift, impaired righting reactions, and impaired balance responses. We hypothesize that impairments of the nervous system together with impairments of the musculoskeletal system resulted in the functional disabilities observed in rolling, rising to sitting, and walking.

We decided to direct treatment first toward relaxation of rigidity and achieving normal passive ROM and active mobility. We specifically emphasized mobility of the supine and pelvic complex. Next, we emphasized achieving normal posture, and finally we directed treatment toward normal use of automatic motor responses and toward better coordinated and quicker movements during functional activities.

Problem identification and interpretation, goal setting, and treatment followed the guidelines outlines previously and will not be discussed in detail. TN was treated for one hour each session, three times per week, for one month. He also performed home exercises that emphasized self-relaxation and ROM of the trunk and extremities three days per week. Evaluation findings prior to and following treatment are summarized in Table 3.

In summary, through physical therapy intervention it was possible to restore the patient's limb ROM to normal limits. Rigidity was positively influenced in that TN was able to use self-relaxation techniques to regain mobility. As anticipated, there was no permanent alteration of rigidity. Righting and equilibrium reactions appeared normal in a supported sitting position. Timing and coordination for most functional activities returned to within normal limits as a result of available ROM, ability to self-relax, and awareness of appropriate movement patterns. These changes are particularly striking given that this individual was not taking any medication for the Parkinson's disease.

Rigidity continued to be a problem for TN in a standing position, and although his balance and gait had greatly improved, he continued to have some loss of automatic righting reactions to the left side. These impairments appeared to result directly from the nervous system pathology. They could not be corrected through physical therapy intervention; however, they no longer interfered with the timing of TN's functional activities. Because of the improvement of TN's status, the decision was made to delay initiation of pharmacologic intervention.

Case 2

"RN" is a 68-year-old retired engineer formally diagnosed with Parkinson's disease in December 1985. Initial symptoms included a tremor of the right hand evident since 1981 and slowing of gait. RN chose to retire early (May 1986) rather than to begin pharmacologic intervention. In September 1986, he began to take Sinemet[R] (*2) (carbidopa-levodopa), which reduced the rigidity, improved timing for movement, and helped him to cope with the disease. Relevant prior medical history included a seizure disorder since April 1981 and a pulmonary embolus in March 1986. RN was referred for physical therapy intervention in February 1987. Evaluation findings prior to intervention and six weeks after treatment began are summarized in Table 4.

This individual's major problems were decreased balance reactions, bradykinesia, and poor coordination of functional activities. These impairments interfered with all aspects of RN's life, but they especially interfered with dancing, which was one of his major social activities. Impairments that resulted directly from nervous system pathology combined with indirect effects of impairments of the musculoskeletal system appeared to account for the observed disability. The effects of those impairments were the same as those discussed in Case 1 and will not be restated here. Problem identification and interpretation, goal setting, and treatment generally followed the guidelines outlined previously. RN was treated for one hour per session, three times per week, for six weeks. Manual and verbal cues were used throughout treatment and especially with new activities to allow the patient to better experience normal movement. Emphasis was on both the timing and coordination of movement. Treatment focused on gait and functional activities early in the intervention period, despite limited gains in trunk mobility. The focus of the treatment approach was on restoration of automatic postural responses within the musculoskeletal constraints. This functional approach was important in giving RN a feeling of success.

Home exercises included relaxation and breathing exercises; static trunk, extremity, and pelvic complex muscle stretching; balance activities; and walking for fitness as well as to reinforce normal gait. RN performed home exercises for at least 45 minutes daily and initiated a walking program.

With physical therapy intervention, RN was able to reduce his rigidity using self-relaxation activities and was then able to improve his ROM. RN's ability to temporarily decrease his rigidity and increase his spinal mobility did allow him to dramtically improve static and dynamic postural alignment (Figs. 1, 2) and dynamic postural adjustments and to increase smoothness of movement by the inclusion of rotational aspects of normal movement. Lumbar extension, lateral flexion, and rotation remained the most limited movements. This lack of lumbopelvic mobility limited weight shifting in the sitting and standing positions and thus limited RN's equilibrium responses.

Following six weeks of physical therapy, RN stated that the quality of his life was much improved. He observed that his square-dancing ability (an important leisure activity) had improved. He was able to take longer steps so that he no longer fell behind. He could also participate in more complex dances. RN also felt more capable to deal with his disease now that he was able to do something for himself. He stated that Sinemet[R] made his improved mobility possible but that physical therapy allows him to maximize his use of that possibility. A big factor in RN's success with treatment was his diligence in performing exercises at home and in consciously incorporating the gains into all of his daily activities.

Summary and Conclusions

The two case studies presented illustrate the changes that occurred in two individuals who received physical therapy early in the course of Parkinson's disease. These changes occurred in one individual who was receiving medication for the disease and in a second individual who was not receiving medication. These individuals initially received therapy three times a week for four to six weeks, respectively.

We hypothesize that physical therapy intervention contributed to these changes, although further study will be necessary to establish the relationship. From our experience providing early intervention with these and other individuals with Parkinson's disease, we would recommend three 45-minute to 1-hour sessions per week for a period of approximately four to eight weeks. This lengthy period of consistent intervention appears to be necessary while the individuals are relearning the feel of normal movement, are becoming adept at correctly performing home exercise, and are recovering as much ROM as possible. Once an individual's gains have reached a plateau, based on quantifiable and subjective measures, it is important that he or she continues daily home exercises. Many patients report that they also find that exercises are a useful component of self-help support groups. After individuals have been discharged from a regular physical therapy program, they should be seen by a physical therapist on an occasional basis to monitor their performance of execises and their physical status. The frequency of follow-up will depend on each individual's capability for self-directed exercise, on the individual's physical status at the time of intervention, and on the rapidity of the progression of the disease process. Follow-up may be set at two-week or monthly intervals initially and then altered as appropriate.

The case studies presented suggest that the disability of Parkinson's disease can be lessened with early physical therapy intervention as gains are made in musculoskeletal flexibility, alignment, and functional movement. They also suggest that the nervous system pathology ultimately limits that improvement. Furthermore, the inability of RN (Case 2) to regain lumbopelvic mobility, especially for lateral flexion and rotation, appeared to limit his recovery of balance responses, suggesting that musculoskeletal limitations in turn limit functional abilities. These observations are being tested in studies currently in progress.

The two case studies presented indicate the importance of physical therapy intervention early in the disease process. The first case study indicates that early physical therapy intervention can delay the need for pharmacologic intervention. This delay is of great importance because long-term use of drugs is associated with potentially unwanted and toxic side effects.[15]

These case studies illustrate a problem-solving approach based on an appreciation of the neuroanatomic pathology of the disease and of the nervous system and non-nervous system impairments that occur. It will be important to establish the efficacy of physical therapy intervention for individuals who are in more advanced stages of the disease, although it might be predicted that gains will be slower and less effective as musculoskeletal alterations become fixed. Finally, studies are needed to experimentally evaluate the efficacy of physical therapy intervention and to compare different intervention strategies. The analysis of Parkinson's disease outlined in this article can be used to experimentally examine the efficacy of physical therapy intervention directed toward physical disability resulting from the different impairments of that disease.

Acknowledgments

We acknowledge Debby Alton, PT, for her contributions to the initial design of the case management technique used in the case studies discussed in this article. We also acknowledge Rebecca Porter, MS, PT; Steven J Rose, PhD, PT, FAPTA; and Steven L Wolf, PhD, PT, FAPTA, for their helpful critiques of an earlier draft of this manuscript.

(*1) 1 ft = 0.3048 m.

(*2) Merck Sharp & Dohme, Div of Merck & Co, Inc, West Point, PA 19486.

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M Schenkman, PhD, PT, is Assistant Professor, Graduate Program in Physical Therapy, MGH Institute of Health Professions, 15 River St, Boston, MA 02108-3402 (USA).

J Donovan, BS, PT, and P Stebbins, MS, PT, are physical Therapy Supervisors, Emerson Hospital, Old Road to Nine Acre Corner, Concord, MA 01742.

J Tsubota, BS, PT, and M Kluss, MS, PT, are Staff Physical Therapists, Emerson Hospital.

RB Butler, MD, is Chief of Medicine, Emerson Hospital, and Assistant Professor, Department of Neurology, Boston University, Boston, MA.