Aims Of Study: The purpose of the study was to assess the functional capabilities of patients with Stage III Parkinson’s disease (PD). Functional status of PD patients declines due to impaired postural reflexes and characteristic loss of balance which became evident at Stage III thus activities of daily living (ADLs) are compromised as the severity of the disease increases.
Methodology: Descriptive case series was conducted on stage III PD patients (n=64). Patients with age ranges from 45 to 75 years were recruited and patients with other neurological issues were excluded. They were assessed using a Functional independence measure scale having reliability 0.95.
Results: Out of 64 patients, 75% required minimal assistance and 9.4% required supervision while performing the ADLs. Whereas, 81% of patients need 2 hours of personal care assistance according to burden of care.
Limitations & Future Implications: Only functional status of PD patient is determined no exercise regime or intervention were incorporated to assess their impact on the PD patient functional activities. Thus, future studies should be carried out to find the correlation between aerobic exercises and their impact on PD patient level of functional independence.
Originality: Information added was all taken from databases and reduced to similarity index and was not submitted to any other journal.
Conclusion: Stage III Parkinson’s disease patient required minimal level of assistance while performing tasks of daily living. However, majority of these patients required 2 hours of personal care assistance on average per day to compete with daily living.
Keywords: Functional status, parkinson disease, cognitive dysfunction, disease progression, orthostatic hypotension, tremors.
Parkinson’s Disease (PD) is a progressive disease involving central nervous system (CNS) eliciting both motor and non-motor complications1. It’s the second most common degenerative disorder with neurological impairments2. It is initiated by loss of nerve cells in substantia nigra due to which brain fails to produce dopamine3. The cardinal features of this disease involve tremors, rigidity, bradykinesia, and postural instability. Secondary motor symptoms include reduction in muscle strength, muscle performance, and gait impairments4. Non-motor signs and symptoms associated are dysphagia, speech disorder, cognitive dysfunction, autonomic dysfunction, orthostatic hypotension, and sleep disorder5. It is prevalent in about 7 to 10 million people worldwide1. While in Pakistan about 450,000 people are affected with Parkinson’s disease6. It is more prevalent in males than females7. On an average 50 to 65 is the age of onset of Parkinson’s disease8.
Hoehn & Yahr (H&Y) classification scale represents the severity of Parkinson’s symptoms and disease progression9. It classifies PD into five stages following the characteristics which patient represents. Stage 1 is unilateral minimum disability, stage 2 bilateral minimum disability without impairment of balance, stage 3 impaired rightening reflex and impaired balance, stage 4 severe disability and assistance required in standing and walking, stage 5 patient confined to bed/wheelchair bound10. The lowest stage 0 is asymptomatic and in stage 5 patient became bedridden11. The modified H&Y scale defines PD severity more broadly, with stages 1 to 2 representing mild disease, stages 2.5 to 3 moderate disease, and stages 4 to 5 severe disease12.
Cognitive dysfunction is evident feature at stage III it drastically drags patients toward postural instability and balance impairment and advanced Parkinson’s disease with characteristic features of dementia, and memory impairment13. Reservation of cognition is essential for mobility and ambulation of patients as the era of disease increases14.With the progression of the disease, mobility of the patient compromises as step length and gait velocity reduces to an extent that the patient became unable to perform Activities of Daily Livings (ADL)15. The patient’s participation in activities decreases tremendously with the progression of symptoms leaving the patient in a socially isolated state16.
Most evident changes in functional capabilities occur at stage III owing to loss of balance and decreased reflexes17. Assessing the Functional status of an individual with Parkinson at an early stage would lead to a better rehabilitation protocol strategy18. When physical therapy interventions are used early in the course of Parkinson’s disease, the disease’s progression can be slowed down, which reduces the burden of the disease and its impairments on society19.
The rationale of the current study is to assess the functional status of patients with stage III Parkinson’s disease so that appropriate preventive and rehabilitative measures can be incorporated at this stage which will helps to preserve the maximal level of functioning and slow down the advancement of the disease.
It was a descriptive case series, n=32 subjects were recruited from the following hospitals of Lahore; Ghurki Trust Teaching Hospital, Jinnah Hospital and Neurology department of Mayo Hospital. The duration of study was from June 2020 to January 2021. The sampling technique used was non-probability convenience sampling. The study was approved by the ethical board of Lahore College of physical therapy LCPT/DPT/16/631. The inclusion criteria were clinically diagnosed subjects of Parkinson Disease at Stage III (Hoehn & Yahr) scale with age ranges from 45 to 75 years that is middle aged and elderly individuals. Patients with other neurological issues were excluded from the study. Written informed consent was taken from each patient prior to study. The patients were assessed using a Functional independence measure (FIM) scale having inter-rater reliability of 0.9520. It contains 18 items composed of 13 motor tasks and 5 cognitive tasks and tasks are rated on 7-point ordinal scale that ranges from total assistance to complete independence. The total score for the FIM motor subscale (the sum of the individual motor subscale items) will be a value between 13 and 91; whereas, cognition subscale (the sum of the individual cognition subscale items) will be a value between 5 and 35. Hence, the total score for the FIM instrument (the sum of the motor and cognition subscale scores) will be a value between 18(lowest) and 126(highest). Thus, FIM is used to assess and grade the functional status of a person based on the level of assistance he or she requires. The inter-rater reliability of FIM ranged from 0.93 to 0.97, while the intra-rater was 0.99 for the motor, cognitive and total FIM score. Cronbach alpha coefficients were 0.97 and 0.95 respectively for the motor and cognitive scores21. Data was analyzed by using SPSS version 21 descriptive statistics were reported and variables are presented in the form of frequencies and percentages.
Out of 64 participants, the minimum age of participants was 45 years; maximum age 78 years with a mean age was of 61.56 and standard deviation (SD) of 9.53 as shown in table 1. Whereas, 75% (n=48) were males and 25% (n=16) were females.
About, 96.9% (n=62) participants were taking medication for Parkinson’s disease and 40.7% (n=26) were suffering from Parkinson’s disease from last 3-4 years as shown in table 2.
Functional status of patient assessed with FIM shows that in motor activities subjects requires assistance or modified dependency in self-care, sphincter control, transfer and locomotion. Eating being the easiest motor task of self-care as 59.4% patients showed moderate independence to complete independence while in stair climbing reported to be a difficult motor task as 84.4% patients required moderate assistance or modified dependency in it. In FIM Cognition subscale the communication task patient need supervision in comprehension and assistance in expression which mean somehow dependency. In social cognition component memory recalling is difficult as 87.4% patients require moderate assistance. Hence, functional status of Parkinson disease at stage Stage III (Hoehn & Yahr) had been shown in table 3.
FIM motor subscale total score shows a mean value 53.19 and SD 8.14 and FIM cognitive subscale total score mean was 21.19 and SD 3.47 as shown in Table 4.
According to the frequency analysis, out of 64 patients, 75% (n=48) required minimal assistance in tasks of their daily life and 9.4% (n=6) required supervision. Whereas, 12.5% (n=8) required moderate assistance and 3.1% (n=2) required maximal assistance in ADLs.
However, 2 hours of personal care assistance is needed per day by 81.3% participants with PD to compete with daily living.
The purpose of the study was to analyze the functional status of patients, hours of care and level of assistance a patient need in stage III of PD by using FIM (functional independence measure) questionnaire so that appropriate preventive and rehabilitative measures can be incorporated by the physical therapist at this stage which will helps to preserve the maximal level of functioning and slow down the advancement of the disease. In 2019, Paul, Chuang, et al. conducted a study to find association between lifestyle factors and Parkinson’s disease progression. He concluded that lifestyle elements decrease the rate of progression of disease22. Macchi, Koljack, et al. in 2019 elaborated that patient and caregiver factors lead to caregiver burden in individuals with PD23. Moreover, in 2019 Feigin et al conducted a systematic analysis and interpreted that neurological burden increases with age and needs to develop prevention and treatment strategies24. Hence, in current study it was found that with the progression of the disease to stage III Burden of care increases.
In 2019, Pelicioni, Menant et al. performed a study on ‘Falls in Parkinson’s Disease Subtypes’ he concluded that patients with Postural Instability and Gait Difficulty are at greater risk of falls owing to functional impairments25. The current study demonstrates that patients with Parkinson’s disease suffer postural difficulties with growing age as the disease progress to stage III, balance impairment starts to prevail. Hence, compared to stages 1 and 2 assistance is required by patients at stage III to accomplish their ADLs. Therefore, it elaborates need for preventive measures to slow down the disease progression.
In 2018, Gupta, Fahn, et al. hypothesized that Hoehn and Yahr scale can be used globally for the assessment of posture, balance, stability, and other movement disorders26. Moreover, Ladislav K Valach et al. in 2017 conducted an observational study indicating the usefulness of FIM in monitoring the patients with PD27. However, in current study patient at stage III of Hoehn and Yahr scale were recruited and functional status of patients were assessed with FIM scale. The study revealed that minimal assistance is required in self-care; moderate to minimal assistance is required in sphincter control, minimal assistance in transfers, and moderate to minimal assistance in locomotion tasks.
In 2017, Yumiko Kaseda et al. conducted a study on the Therapeutic effects of intensive inpatient rehabilitation in advanced Parkinson’s disease and found FIM motor average value 52-63, FIM cognitive average value 26-27.6, and total FIM score of 78-9028. In the current study, it was concluded that at stage III patients with Parkinson’s disease require minimal assistance to accomplish activities of daily living revealing a consistency of results with the previous study.
In 2021 Yang Li et al. conducted a systemic review to assess the efficiency of aerobic exercise among Parkinson’s disease patients and concluded that moderate aerobic exercise improves balance and gait in PD patients. Exercise of various kinds has diverse effects on PD patients’ quality of life. It is imperative to systematize the exercise program additionally29. Whereas, in the current study only the functional status of PD patient and their level of assistance is determined no exercise regime or intervention were incorporated to assess their impact on the PD patient functional activities.
Thus, it is recommended that future studies should carried out to find the correlation between aerobic exercises and their impact on PD patient level of functional independence.
According to the results of this study, it was reported that patients with Stage III Parkinson’s disease required minimal level of assistance while performing tasks of daily living. However, majority of these patients required 2 hours of personal care assistance on average per day to compete with activities of daily living.
The study has been approved by the Ethical Board of Lahore College of Physical Therapy LCPT/DPT/16/631.
Written Informed Consent was taken from each patient.
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This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0). https://creativecommons.org/licenses/by/4.0/
Conflict of Interest: The author (s) have no conflict.
[i] Student, Physical Therapy Department, Lahore College of Physical Therapy, LM&DC, Lahore, Pakistan (0000-0003-1059-2970)
[ii] Senior Lecturer, Neurosciences Department, Lahore College of Physical Therapy, LM&DC, Lahore, Pakistan (0000-0003-1686-7250)
[iii] Demonstrator, Applied Science Department, Lahore College of Physical Therapy, LM&DC, Lahore, Pakistan (0000-0001-7621-2307)
[iv] Professor, Lahore College of Physical Therapy, LM&DC Lahore Pakistan (0000-0002-2039-7119)