Alzheimer’s disease (AD) is a common dementia characterized by loss of memory and other cognitive abilities. The role of physical therapy in AD patients is to address any structural and functional impairments and to help patients overcome their mobility and participation limit. In addition, the role of a physical therapist has been found to help prevent the progression of physical and cognitive decline .
The following is a fictional case study about a patient named Mrs. G. The purpose of this article is to discuss the clinical presentation and physical therapy of a semi-professional pianist with AD. Mrs. G is an 87-year-old woman with a two-year history of AD. recent Nursing staff at Mrs G’s Nursing Home found that she was cognitively impaired and a physiotherapist was consulted. In Mrs. G’s assessment, significant deficits in balance cognition and fine motor control were noted. The main goals of Mrs. G’s treatment plan are to Improve fine motor skills to regain the ability to play the piano. The treatment plan also includes balanced gait endurance and flexibility exercises. After the intervention, Mrs. G’s wrist extensor strength and Timed Up and Go Berg balance scale scores improved, and Action Research Arm Test. Physical therapy interventions ultimately reduced her risk of falls by strengthening her balance and increasing the strength of her wrist extensors to help her play the piano. Mrs G should continue to receive monthly physical therapy to monitor her condition and improve her health training.
- AD = Alzheimer’s Disease
- ADL = activities of daily living
- ARAT = Action Research Arm Test
- AROM = active range of motion
- BBS = Berg Balance Scale
- b/l = bilateral
- CoG = centre of gravity
- CVD = cardiovascular disease
- FAQ = Functional Activity Questionnaire
- IADL = Instrumental Activities of Daily Living
- L = left
- L/E = lower extremity
- MMSE = Mini-Mental State Exam
- MMT = manual muscle test
- R = right
- TUG = Timed Up and Go
- U/E = upper extremity
- WHOQOL-BREF = World Health Organization Quality of Life-BREF
- WNL = within normal limits
Alzheimer’s disease is defined as a progressive neurodegenerative disorder that affects memory and cognition . Common Alzheimer’s disease is the most prevalent pathophysiology in older adults, responsible for approximately 60-80% of dementia cases . Some key risk factors include age >65 Genetic factors such as family history of hypertension and obesity .
The following video provides an overview of dementia and recommended strategies for supporting people with dementia .
The deterioration of neurological function is due to the death of brain cells, mainly caused by plaques that block nerve signals and tangle proteins that prevent the circulation of nutrients to neurons . The clinical manifestations of the disease vary widely between patients, depending on the site of disease Brain inflammation and atrophy. Common signs and symptoms of Alzheimer’s disease include memory impairments that address reasoning, comprehension, attention, and orientation .
Several researchers have explored the role of physical therapy in Alzheimer’s disease management on a case-by-case basis. In one case study, researchers collected qualitative data by interviewing two patients and their spouses to investigate participation in Physical activity and Alzheimer’s disease . In addition, a systematic review was conducted to address barrier facilitators and motivators for participation in physical activity in patients with Alzheimer’s disease. This study identified the importance of caregiver involvement and Individualized exercise programs to promote physical activity participation in this population .
In patients with Alzheimer’s disease, physical therapy has been shown to maintain independence through mobility exercises and functional task training . Physiotherapy has also been shown to prevent falls by enhancing stability postural control and balance training . and Physical therapy can help manage behavior and emotions through pain management and regular exercise . In addition, physical therapy may be protective of cognitive function and may help delay neurological decline .
Despite the benefits of physical therapy mentioned above, Alzheimer’s disease patients are at higher risk of longer hospital stays, lack of access to healthcare, premature institutionalization and inadequate care that does not meet their goals [14 ]. This highlights the importance Rehabilitation interventions aimed at prolonging function and maintaining independence in this patient population.
The purpose of this fictional case study was to explore the role of physical therapy in maintaining functional independence and delaying neurological decline in patients with Alzheimer’s disease. Specifically, the patient exhibited multiple cognitive deficits, including short-term Memory loss and behavioral changes and movement disturbances in fine motor control balance and coordination. The following sections explore various assessment techniques and intervention strategies aimed at enhancing participation in physical activity and optimizing an individual’s quality of life have Alzheimer’s disease.
Mrs. G is an 87-year-old woman with a two-year history of Alzheimer’s disease. She is relatively healthy and active despite having comorbidities such as high blood pressure and osteoporosis. Mrs. G is a 41-year-old retired English teacher and semi-professional pianist who started Played in her early childhood. After her diagnosis, Mrs. G’s family decided to move her to a nursing home to ensure she was well supported by nursing and personal support staff. Last month, nursing staff at her nursing home noticed a remarkable She had a decline in cognitive function, including short-term memory deficits, confusion, paranoia, and recurrent irritability. However, her long-term memory has not yet been an issue. In response to these findings, they consulted with a physical therapist to address Ms. G’s concerns. during physiotherapy Assessing Mrs. G indicates that she is having difficulty playing the piano. She reported feeling as if her hands couldn’t move the way they used to, which made it challenging to play complex songs. As a person, she is particularly troubled by deficits in upper body fine motor skills One of her favorite activities is playing the piano every evening. Mrs G also said she lost her balance walking around the nursing home, making it harder to take part in her daily walks and fitness classes.
Patient profile: 87-year-old female, retired English teacher, semi-professional pianist.
History of Present Illness: Ms. G was diagnosed with Alzheimer’s disease two years ago. Over the past month, she has developed fine motor balance and coordination deficits that have disrupted her piano playing and daily physical activity. As noted by paramedics, she emerged Short-term memory loss and paranoia.
Past medical history: Bilateral knee meniscus repair surgery was performed six years ago. History of hypertension and osteoporosis.
Drugs: Bisoprolol Aricept and Memantine.
Healthy Habits: Former smoker (8 years old), no current alcohol drinker.
Family history: Mother passed away at age 98 from Alzheimer’s disease. The father has a history of cardiovascular disease.
Social History: Mrs. G is a widow who currently lives alone in an apartment in a nursing home with some assistance with daily living. She has two daughters who live within a two-hour drive of the nursing home and visit most weekends. Mrs. G plays the piano all day and enjoys interacting with others resident. She takes daily walks in the garden with friends and attends weekly fitness classes at the residence.
Previous functional history: Ambulatory without gait assistance for 30 m with minimal fatigue. Able to play piano for 30 minutes per day with no coordination difficulties.
Precautions/Contraindications: Short-term memory loss and paranoia may interfere with learning new exercises and adhering to the treatment plan.
- Forward stooped posture
- Thoracic kyphosis
- No use of gait aid
- Slow movement showing signs of bradykinesia
- Able to walk 10 meters before losing balance
- Broad support base and notable instability
- Shortened gait cycle
- Significant decrease in concentration and concentration
- Forward stooped posture to adjust CoG
- Cervical AROM: L and R rotation ½ range
- Shoulder AROM: WNL b/l
- Wrist AROM:
- R wrist flexion full ROM
- R Wrist extension ¾ limited by muscle weakness
- L wrist flexion full ROM
- L wrist extension full ROM
Manual Muscle Tests:
- Shoulders: 5/5 for all movements b/l
- Elbow: 5/5 for all movements b/l
- Wrist: moderate weakness painless with poor motor control b/l. R Wrist extensor strength rating 3/5.
- L/E: 3/5 mild weakness painless and slight motor control deficit b/l
- Mini-Mental State Examination (MME): 18/30 points
- Mini-Cog Test: score of 2/5
- Timed Start Test (TUG): 14 seconds
- Berg Balance Scale (BBS): Score of 40/56
Fine Motor Control Tests:
- Action Research Arm Test (ARAT): Score of 25/57
- Fingers to nose: smooth coordination with slight dysmetria R>L
- Finger opposition: moderate impairment R>L lack of coordination
Self-Reported Outcome Measures:
- WHOQOL-BREF: Score 66/100 (Physical), 84/100 (Psychological), 72/100 (Social Relations) and 81/100 (Environmental)
- Functional Activity Questionnaire (FAQ): Score 12/30
During the subjective interview, Ms. G described difficulties with fine motor control balance and hand coordination. This affected her ability to perform activities of daily living, such as brushing her teeth and dressing. Patient becomes more fatigued while playing the piano Deficits in coordination and muscle strength. She also had severe short-term memory deficits and showed signs of paranoia. The weakness she encountered in L/E could be a factor causing the loss of balance, while her weakness in U/E can be attributed to her reduced abilities Play the piano and complete fine motor tasks.
The patient’s TUG score of 14 seconds indicated that she was at high risk of falls and dependent in the community . Furthermore, her BBS score of 40/56 was consistent with the balance problems she was experiencing and also put her at moderate risk for falls . Mrs. G receives points An ARAT of 45 indicates that her U/E performance has moderate recovery potential. She scored lowest in 16 items reflecting fine motor movements of the hands and fingers . Her performance on the finger-to-nose test and the finger-opposite test showed a decline in fine motor coordination reveals mild dysmetria . Her FAQ score was 12/30, suggesting functional and possible cognitive impairment, especially in IADL . Mrs G’s scores on the WHOQOL-BREF indicated a slightly below average quality of life in the physical domain . her cognition Ability was assessed using the Mini-Mental State Exam and Mini-Cog Test, both of which revealed mild and clinically significant cognitive impairment  . Overall, these findings support the classification of Mrs. G’s impairment as mild Alzheimer’s disease.
- Decreased ability to perform IADL based on FAQ scores
- Decreased fine motor control and hand coordination affected her ability to play the piano
- Decreased balance, characterized by instability and loss of balance within a 10-meter walk
- Problems with certain daily activities (hygiene and dressing) due to fine motor impairment
- Cognitive impairment, including components of the Mini-Cog test, short-term memory loss and behavioral changes
- Improves BBS score to 46/56 within 6 weeks to reduce risk of falls and increase gait balance.
- Improves ARAT score from 25 to 20 in 6 weeks to restore fine motor loss.
- Increase the TUG score to 10 sec within 10 weeks for classification as independent and low risk for falls.
- Ability to play a song on the piano 2 times/week within 12 weeks with minimal finger and hand muscle fatigue.
- Maintain an MMSE score of 18 during the 12-week treatment period to prevent cognitive decline.
The management plan was developed taking into account Mrs. G’s condition target values and settings. The main issue to address was to determine that her difficulty with fine motor control of her hands and fingers would affect her ability to play the piano and perform ADL. as well as It was considered important to determine that her decreased lower extremity strength had affected her balance and gait. Second, her cognitive and behavioral changes were identified as components to be maintained or improved. Multicomponent training has been shown to be effective in improving Functional performance in elderly AD patients has a positive impact on upper and lower extremity strength endurance agility and balance . Therefore, to specifically address these issues and achieve her goals, the following program was developed:
Fine Motor Skills and Coordination
It was important for Mrs. G to work on her fine motor and coordination skills, as these deficits affected her ability to play the piano and perform some ADLs. Nailboard drilling finger-against and finger-to-nose tasks require hand-finger coordination and accuracy. has shown that when Individuals with AD who practice a task repeatedly can retain motor skills for more than a month after training . AD patients also showed significant improvement in task performance during early practice and maintained this learning over the course of the trial . so practice Fine motor skills that mimic meaningful functional tasks could improve Mrs. G’s ability to retain these skills and maintain her independence and quality of life.
Decreased balance and mobility have been observed in individuals with AD . As balance has been shown to be a strong indicator of fall risk , it is important to address this issue. To improve Mrs. G’s balance, she needs to practice challenging balance tasks that force her to overcoming challenges . Some exercises that have been shown to improve balance in AD include weight shifting, side steps, and tandem walking . Based on Mrs. G’s initial balance level check, the balance exercises used were center of gravity shift and internal perturbation train. As Mrs. G’s balance and strength improved, it was expected that the abnormal component observed in her gait (a shortened gait cycle broadly supporting the basis of slow movements) would also improve. These improvements may have positively impacted her postural stability and kyphosis posture, as walking impairment may affect posture in AD patients .
Strength, Endurance, and Flexibility
On objective examination Mrs G’s forearm extensors and lower extremities were found to have some weakness. These weaknesses may affect her fatigue while playing the piano and her difficulty with balance and walking. Resistance training has been observed to increase agility strength Balance and flexibility in AD patients . Therefore, by implementing exercises that promote lower and upper body strength, she will likely see improvements in piano playing balance and walking. Exercises focused on her lower body strength include braces ½ squat supports both leg calf raises and standing hamstring curls. These exercises target the major muscle groups required for walking and balance . Resistance training has also been shown to significantly improve an individual’s TUG score , which translates into improved ambulation and reduce the risk of falls. In order to strengthen the playing endurance of Ms. G’s forearm and finger flexors and extensors, she was given lunch box strength training. This exercise allows her to practice several important hand movements with ease and resistance. above For best results, strengthening exercises will be performed 3 times per week . Ms. G’s plan also included a stretching exercise because studies have shown that stretching reduces post-exercise soreness  and that flexibility exercises are beneficial for cognitive tasks and behavior .
Cognition and Behaviour
Walks at the nursing home were included in Mrs. G’s exercise program because she reported in subjective interviews that she enjoyed walking with other residents. Aerobic exercise has been associated with improved neurocognitive performance . Cardiorespiratory fitness is proven slows functional decline in AD patients, thereby positively affecting their independence . Research has shown that 20-30 minutes of daily aerobic exercise can provide these benefits . Her walking is adapted through the use of gait aids and/or assists, so Mrs. G Reap the benefits of improved cardiorespiratory fitness without the risk of falls.
Music as a therapeutic therapy for personal body-emotional cognition and social needs has been well documented in previous literature . Musical support therapy, in which the patient produces scales and simple melodies on an electronic piano or electronic drum set Enhances cognitive function in the areas of verbal memory and attentional concentration . It has also been shown to improve depressive symptoms and mood, both of which are common in AD patients . Likewise, singing in choirs showed significant improvements in boosting mood and energy Participation in interactive enjoyment improves motivation and stress release and relaxation . Participation in choirs has been shown to improve an individual’s quality of life as measured by the WHOQOL-BREF questionnaire . Both music therapy and choir make sense Intervention for Mrs. G because she loves music and socializing.
The literature supports the use of multicomponent training as shown in Mrs. G’s exercise program to improve functional performance in older AD patients. To reap the benefits of the program, daily walking and stretching will be done while strength training will be Do this 3 times a week. However, there is little evidence on frequency protocols for the fine motor skills and balance training aspects of the program; therefore, these tasks will be performed in groups 1-2 times per day as Mrs G can tolerate. Recommended Program Intensity A modified Borg Perceived Effort Scale score (0-10) was used because Mrs. G’s maximum effort on many of these tasks was not known a priori. As shown, as Mrs. G improved in these exercises, she moved into a more difficult version to continue gaining function. This The prescribed interventions have been shown to improve the identified key problem areas and may help Mrs. G achieve her goals. Certain interventions overlap to achieve the same goal. For example, resistance training has been shown to increase strength and balance. Music Support Therapy is also shown To improve cognitive and fine motor skills. The plan takes into account Mrs. G’s baseline functioning, aligns with her interests and values, and includes setting specific tasks and her goals for improvement.
Following an assessment of Ms G’s case, a three-month physiotherapy program was implemented. Her treatment plan aimed to improve her fine motor skills, hand coordination, standing static balance and gait dynamic balance. The program includes three physiotherapy sessions per person For one week, focus on strength and endurance. Mrs. G also does fine motor control activities and balance exercises daily. Follow-up physical therapy was given weekly for the first month and every two weeks thereafter.
During the three months of treatment, Mrs. G’s U/E MMT improved slightly. Mrs. G’s R wrist extensor strength was significantly improved to grade Ⅳ. Likewise, Mrs. G’s R wrist ROM improved to a near full ROM. These improvements will help Mrs. G play the piano.
Her outcome measures scores after the physical therapy intervention were as follows:
- MMSE = 18/30
- Mini-Cog Test = 2/5
- TUG = 10 seconds
- BBS = 45/56
- ARAT = 35/57
- FAQ = 12
The MMSE and Mini-Cog tests showed the same scores before and after treatment, indicating no change in the cognitive status of the patients. These tests will continue to be used to track Mrs. G’s cognitive status over time. Combination of strength endurance balance and coordination The exercise lowered Ms. G’s TUG score by 4 seconds, reducing her risk of falling. Mrs G showed a positive response to the balance intervention with a clinically significant improvement in her BBS score. Mrs. G’s BBS rating increased by 5 points Especially improvements in standing unsupported with eyes closed and standing with feet together. The ARAT was used as an assessment and treatment tool, showing a 10-point improvement. These improvements were highest in the fine motor categories within the grip And pinch the scales.
Mrs. G should continue to attend monthly physical therapy visits to track her improvement, address any new issues, and advance her exercise. These appointments will help her manage her coordination balance and fine motor control to enhance her piano playing and walking ability. Mrs. G should also be monitored for secondary damage as the disease progresses. In addition, Mrs. G will be referred to an occupational therapist for a home safety assessment with activities of daily living and dressing aids, as well as other adaptive equipment she may require. In the near future, Mrs. G’s mobility and cognitive status should be reassessed to determine the possible use of assistive devices to maintain her safety.
This case study outlines the physical therapy evaluation and intervention plan for Mrs. G, a semi-professional pianist with Alzheimer’s disease. Her main complaint was a reduced ability to play the piano and participate in physical activities in the nursing home where she lived. Clinically she Wrist extensor strength, fine motor skills, and balance were impaired, classifying her as at increased risk for falls. Following a physical therapy evaluation, she enrolled in a three-month treatment program focused on her individualized rehabilitation goals. Exceed During the intervention, she completed three physical therapy sessions per week focusing on strength and endurance. She completes fine motor skills activities and balance exercises daily. Mrs. G attended follow-up meetings weekly for the first month and biweekly for the second through third months. This Physical therapy interventions reduced her risk of falls, enhanced her balance in her gait, and increased her wrist extensor strength, ultimately enabling her to regain the ability to play the piano and participate in physical activity.
A unique finding in the case of Ms. G was that although she was able to memorize all of her piano pieces, she still had difficulty controlling her hands. The fine motor tasks of piano playing are stored in the brain as a motor program, whereas the memory component of the music will be stored in a separate brain area. therefore This inconsistency may be due to the fact that Mrs. G’s brain regions were affected by the disease pathology, leaving her cognitive skills intact while her motor skills were impaired. In this case, outcome measures included action research arm tests, finger-to-nose tests, and The finger confrontation test was used to assess Mrs. G’s upper extremity fine motor control and coordination. By using these objective assessment tools to quantify Mrs. G’s dyskinesias, physical therapists can develop an individualized intervention plan targeting areas of need Improve.
There are many case studies in the literature investigating the role of physical therapy in the treatment of older adults with Alzheimer’s disease. Like Mrs. G, many patients with this disorder develop cognitive symptoms such as short-term memory loss and changes in chaotic behavior, including Aggression and paranoia and motor deficits in balance coordination and fine motor skills . There is strong evidence that physical therapy can help manage Alzheimer’s disease by helping to maintain independence, prevent falls and delay cognition Descend.
Despite the well-known benefits of physical therapy management, patients with Alzheimer’s disease and related neurologic disorders have higher rates of health disparities, which are associated with loss of autonomy in living independently and making decisions about health care plans . click below Link to learn more about some of the key health disparities related to the stigma surrounding various forms of dementia: Alzheimer’s Association 2017 Awareness Survey.
Several factors may contribute to health disparities in patients with Alzheimer’s disease . Some examples include:
- Lack of autonomy and participation in care planning
- lack of participation in sports interventions
- Lack of social support leads to poor mental health and problem behavior
- Healthcare providers lack disease-specific education and training
As an integral member of the care team, physical therapists can be important advocates for people with Alzheimer’s disease. First, physical therapists can implement patient-centered care by discussing patient-centered goals, considering the patient’s values and beliefs, and treating the patient With dignity and respect. Second, physical therapists can promote autonomy by informing patients of their rights, supporting patients’ decisions and ensuring patients have adequate access to health care. Third, physical therapists can actively listen by spending time Patients build therapeutic rapport to enhance emotional comfort and encourage active participation in their treatment plan.
The main goals of physical therapy intervention in this population should include maintaining independence and optimizing quality of life. Several ways to achieve this are outlined below.
- Enhance patient autonomy by providing choice wherever possible
- Emphasis on functional task training to enhance ADL and IADL independence and reduce the burden on caregivers
- Take the time to understand the individual needs of patients in order to provide patient-specific resources
- Educate caregivers about services available in the community to prevent burnout
In addition to the recommendations above, the following provide some general guidelines that physical therapists can use when treating patients with Alzheimer’s disease.
- arrange routine treatment
- Ask simple, specific questions
- Focus on one task at a time
- Minimize distractions in the environment
- Maintain patient dignity at all times
- Introduce yourself and your character in every interaction
- Ask about symptoms frequently
- Talk to the patient rather than the caregiver whenever possible
Due to the nature of Alzheimer’s disease, communication can be a challenge for physical therapists. The following video provides suggestions for enhancing communication with people with dementia .
To put these strategies into practice, physical therapists can enhance verbal communication by providing simple step-by-step instructions and speaking slowly with frequent pauses to allow sufficient time for information processing . Additionally, it is possible to use the actions or images to explain tasks while paying attention to using non-threatening body language . Furthermore, communication can be enhanced by active listening and showing empathy .
All in all, physical therapy is an integral part of managing the symptoms of Alzheimer’s disease, helping to improve the patient’s quality of life and independence. It is important that physiotherapists work with interprofessional care teams to provide Personalized care aligned with patient goals . Physiotherapists can use a variety of strategies to facilitate open communication and provide effective patient care while considering the impact of illness. By providing patient-centered care, physical therapists can help Patients maintain physical and cognitive function, enabling them to participate in meaningful activities within their communities.
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