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Shifting Rehab Paradigms

The Other Movement Disorder

Published January 6, 2017 1:47 PM by Viktoriya Friedman

Parkinson’s disease is best known for how it manifests itself: presenting with gait and movement dysfunction related to dopamine depletion. What about other movement disorders?

Though diseases such as progressive supranuclear palsy, Lewy body, multiple systems atrophy and corticobasilar degeneration may present similar to idiopathic Parkinson’s disease, there are clinical features that differentiate them. For the first time, in my professional carrier, a patient with a different kind of movement disorder was referred to me – akathisia, which is a scientific word for severe, drug-induced restlessness. The reason for physical therapy: falls

Parkinsonism, related to antipsychotic or neuroleptic medications, presents very similarly to idiopathic PD. Patients display bradykinesia, rigidity and mask-like facies, but they have an underlying psychiatric condition that requires treatment with antipsychotic or neuroleptic medications. Akathisia, on the other hand, presents differently. It resembles severe agitation, leg tapping, and constant movement can be debilitating for patients and can cause imbalance.

It is important for therapists to recognize this manifestation of drug-induced movement disorders by taking a thorough initial history and being aware of medication adjustments. Though akathisia is generally resolved when neuroleptic medications are discontinued or modified, physical therapy for balance and strengthening can be very beneficial. Gait training that focuses on amplitude mitigation and stride-length cadence improvement can help to improve gait rockers. Balance exercises that include dynamic gait and multitasking, pacing and stopping to make safe decisions can improve fall prevention strategies. 


Viktoriya, I found this article very interesting and beneficial, as I am getting ready to enter the profession as a new grad. In my recent clinical rotations, I have treated several patients with PD and other movement disorders, including MSA and drug-induced Parkinsonism. I was not aware of akathisia and I thank you for bringing it to attention. I treated one patient on the psychiatric floor while on my acute rotation. He had a dx of schizophrenia, but was recently admitted for a violent episode, resulting in catatonia. He was being treated heavily with antipsychotic meds, and now presenting with parkinsonian symptoms. We were asked to evaluate and treat as he was "no longer able to transfer or ambulate" according to nursing. After a quick evaluation, we were sure to make the MD aware of the possible need to reduce his medication due to his motor symptoms. We also treated him with amplitude focused interventions, and we did see some improvements. It is so important to be aware of differential diagnoses before we focus too much on treating a more "obvious" condition.

Rachel, SPT April 20, 2018 10:08 AM
Greenville NC

Thanks Viktoriya for providing insight on this differential diagnosis.  I am currently a 3rd year DPT student about to graduate in May of 2017, and during my 3 years of DPT school, I have seen many therapists make quick diagnoses when patient's come into the clinic.  Yes, a lot of the times the diagnoses are correct, but there have been times when the physical therapist incorrectly diagnosed the patient.  I could definitely see this being one of those instances that frequently gets misdiagnosed.  As you wrote, there would be a lot of similarities in treatment, but if the physical therapist does not recognize that changing the patient's medications can lead to a substantial improvement, then the physical therapist is doing a disservice to the patient.  It is very important that physical therapists identify all of the person's impairments and potential causes for their impairments.  From a personal standpoint, I could definitely see myself overlooking the possible link between the patient's medications and their impairments, and I could see myself treating the patient as if they had Parkinson's Disease.  With practice and clinical experience, I hope to broaden my skills/clinical decision making as a physical therapist and view each patient from a more holistic angle.  

Keith Bumgardner, Student April 12, 2017 2:23 PM
Greenville NC

Thanks for providing insight on this differential diagnosis. I can see how it would be easy to treat this condition similarly to Parkinson's,when really changing medications may offer substantial improvement. As you wrote,I think it's also important to note that physical therapy is still an appropriate intervention as falls are common in this population,and just in elderly patients in general. I think this truly highlights the opportunity for physical therapists to be an advocate for their patients,however. As we all know,PTs do not prescribe drugs,and therefore sometimes can provide an objective eye into a medication situation. It is always important to review a medication list,do research on drug interaction,and ultimately communicate with the patient's doctor when signs and symptoms don't make sense. Working as a team with other healthcare professions will not only improve relations with other providers,but will also increase the value of our profession.

Christina W, Physical Therapy - Student April 10, 2017 10:12 AM
Greenville NC

Thanks Viktoriya for this insight. I am currently a 3rd year DPT student navigating my final clinical rotation in a setting heavily skewed to the geriatric population. In my short time here, I have already seen a plethora of neurologic and motor control disorders. Medication lists seem to be even more extensive. Unfortunately, I feel this often gets cast aside by many in the PT profession. From a personal standpoint, I feel that I often fall victim to solely pinning a patient's diagnosis to physical deficits. I hope that with practice, along with insight such as this, I broaden my examination lens and view each patient from a more holistic angle.

Ben January 18, 2017 10:25 PM

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