therapy Assessment
This section has been designed for therapists to use in their assessment of clients. It includes testing endurance, walking/ambulation, balance/fall risk, and mobility. There will be questionnaires and tests for the client to complete in the clinic. Clients should ask questions about the tests. They will receive a copy of the results.
Functional Assessment
Doing a full evaluation/assessment of the client with Parkinson disease (PD) is always important. This part of the website will review what you might want to learn during this initial session. It is important to do a full evaluation before starting an exercise program. The evaluation gives a direction/focus for both the client and the physical therapist (PT). In fact, this population lives longer than the normal population and they are often healthier. Re-do the evaluation every 6 months or at least once a year. Remember that PD almost always starts unilaterally and can start in an arm or a leg. Depression, sleep disturbances, balance problems and a flexed posture are common hallmarks.
Functional Assessment
Doing a full evaluation/assessment of the client with Parkinson disease (PD) is always important. This part of the website will review what you might want to learn during this initial session. It is important to do a full evaluation before starting an exercise program. The evaluation gives a direction/focus for both the client and the physical therapist (PT). In fact, this population lives longer than the normal population and they are often healthier. Re-do the evaluation every 6 months or at least once a year. Remember that PD almost always starts unilaterally and can start in an arm or a leg. Depression, sleep disturbances, balance problems and a flexed posture are common hallmarks.
An example of how to do an exercise write-up:
subjective Assessment
1. Questionnaires:
- Have the client do the Activities Specific Balance Scale (activities_specific_balance_scale.docx) , the Parkinson Disease Questionnaire, and the first 2 parts of the UPDRS while they are waiting for the therapist. (Do not let anyone help them except someone you have trained.) It will be good to see how they write.
- Ask about medication and write them all down—you should know when they started on each of these. With l-dopa (carbidopa/levodopa) you want to know what they are using, for example 3 tabs of 25/100 would be 75/300 for the day. A dose using controlled release is 50/200 and 3 tabs would be 150/600. Are they using any dopamine agonist (the most common ones are Mirapex/pramipexole and Requip/ropinirole) and what doses? There are other PD drugs. Are they on a sleeping pill and/or an antianxiety or antidepressant medication? It is important to know if any of their other drugs could lower blood pressure. Hypotension and dyskinesia are the two common problems with these drugs. Clients who develop confusion and/or hallucinations should contact their physician to adjust the medication.
- Ask about bowel and bladder. How many times did they get up last night and the night before? Ask if they have had any accidents related to bowel and bladder in past 6 months.
- Question regarding current activity routine, any exercise programs in the past 3 years, and what they want for the future? When did they last use the aerobic equipment they own or could use at the place they belong?
- When has the client had their last fall? Get the details of the fall. Did they remember the fall? Could this have been a hypotensive problem?
- Usually they do not start with severe pain, increased tone, integumentary problems, vision and hearing problems, range of motion, sensory integrity, ventilation and respiratory/gas exchange problems, circulation problems, reflex and cranial nerve problems. If they have some of these problems it could be due to another disease.
objective assessment
- A weight, height, resting blood pressure (BP) in sitting and standing BP if they say they get light headed/dizzy.
- Assess the movements of the facial muscles
- Assess the strength of the hip extensors, back extensors, ankle planter flexors and full range of the shoulders.
- Balance, Mobility, Ambulation
Balance:
Balance may become a problem in people with Parkinson Disease (PD). Higher level clients should start with single leg stance (30 sec) and sharpened Romberg (tandem stance) with eyes open and eyes closed (60 sec). Many older individuals will be able to do the sharpened Romberg with eyes open but will score much lower with eyes closed. This informs the therapist that the client is visually dependent for most of their activities. Working in therapy on feeling movement rather than seeing movement may help the client in many situations where vision is reduced.
For clients who struggle with balance or have falls, a full balance assessment should be performed. These include the Berg Balance Test, or the Mini Bestest. These tests are ordinal scales and cutoffs can be used to help predict falls.
It is also good to use the Activities Specific Balance Scale (ABC), where clients answer questions about their concerns with loss of balance. This test is often used when the client checks in for therapy the first time. The test tells the therapist if the scores on ABC test are similar to the scores on the other tests like Single Leg Stance or Berg Balance Test. Therapists then can ask, "Is this client an over-achiever or under-achiever?" This does make a difference in a therapist's approach.
Included below is a few files on a variety of functional balance tests that can be used . For example, the Functional Reach in 4 Directions: It is nice to use the Backwards Reach as therapy progresses to see if the client is improving. Clients could loose their balance during these tests so its important to properly guard clients always.
For clients who struggle with balance or have falls, a full balance assessment should be performed. These include the Berg Balance Test, or the Mini Bestest. These tests are ordinal scales and cutoffs can be used to help predict falls.
It is also good to use the Activities Specific Balance Scale (ABC), where clients answer questions about their concerns with loss of balance. This test is often used when the client checks in for therapy the first time. The test tells the therapist if the scores on ABC test are similar to the scores on the other tests like Single Leg Stance or Berg Balance Test. Therapists then can ask, "Is this client an over-achiever or under-achiever?" This does make a difference in a therapist's approach.
Included below is a few files on a variety of functional balance tests that can be used . For example, the Functional Reach in 4 Directions: It is nice to use the Backwards Reach as therapy progresses to see if the client is improving. Clients could loose their balance during these tests so its important to properly guard clients always.
Mobility:
There are two tests commonly used in this population to judge overall movement. They are both simple tests that can be done in less than a minute. The first is the Timed Up and Go (TUG). This mobility test involves a sit to stand, walking, turning and a stand to sit. You should document the quality of the turn because turning more effectively may be a goal for the client. The other test is the 30 second sit to stand test. Use the standard fixed mat in therapy or a chair with no arms. This activity often becomes a goal in therapy. Clients can practice this at home, when getting in and out of the car, on and off the toilet or bed.
Ambulation/Walking:
Ambulation/Walking is an area that most clients with PD have problems with. The Six-Minute Walk Test is a test of endurance. With intervention this should be one of the easiest tests to change over time. (See article regarding this test.) The Comfortable and Fast Gait Speeds test is also valuable (use 6 meters if you can). A client who cannot change time on this test when you tell them to walk fast will have many goals in therapy. Clients with PD will often score below the norms for people their age on both of these tests. The therapist can use minimal detectable change (MDC) scores to set goals. These are available in the MDC paper posted below. These tests are reliable and valid.
The Functional Gait Assessment (FGA) test is an ordinal scaled test that allows the therapist to have the client do dual tasks. The same 6 meters you used for the gait speed can be used for this test. The test goes fast (10 minutes) once the therapist has done it a few times. It is an ordinal scaled test that developed from the Dynamic Gait Index. This test tells the therapist where the upright balance problems are with clients. New FGA reliability and MDC (95) have been published.
The Functional Gait Assessment (FGA) test is an ordinal scaled test that allows the therapist to have the client do dual tasks. The same 6 meters you used for the gait speed can be used for this test. The test goes fast (10 minutes) once the therapist has done it a few times. It is an ordinal scaled test that developed from the Dynamic Gait Index. This test tells the therapist where the upright balance problems are with clients. New FGA reliability and MDC (95) have been published.
Quality of Life Measurements
Movement Disorder Society –United Parkinson Disease Rating Scale (MDS-UPDRS) can be found at www.movementdisorders.org. The MDS-UPDRS is an international scale but also is long. Make sure to use the latest version. It should be done initially and then every year thereafter. The other popular scale is The Parkinson’s Disease Questionnaire (PDQ); there is a 39 version and an 8 version and both are available on the internet. The following people have been instrumental in its design: Crispin Jenkinson, Ray Fitzpatrick and Viv Peto. Clients are not too excited about this test. A therapist could use the 8 point scale in the waiting room before the start of a session. There is a nice manual the therapist can order from the University of Oxford called "The Parkinson's Disease Questionnaire". It includes everything the therapist would need.
Assessment and Goals
Assessment and goals for the client needs to be decided with the client. Below there are two ways to write an assessment based on whether the therapist wants to use normative data or cut-off scores. For people who are bradykinetic (slowness of movement), use community norms as the baseline (see 6MWT below). To decrease the risk of falls, use cut-off scores (see the Berg). It is important to consider assessment in mobility (Timed Up and Go, 5 Timed Sit to Stand). To assess walking/ambulation use the Six Minute Walk Test (6MWT), Gait Speeds, and Functional Gait Assessment. Articles related to these tests are in the Steffen and Kloss article entitled "Toolbox of Outcome Measures for Individuals with Parkinson’s Disease" (listed above).
If concern exists about the client having the endurance to walk in the community use reference data (you can do this with the 6MWT, gait speeds and the Timed Up and Go). For example, in a 6 minute walk test, walking 100 meters with 1 rest [independent community males, 60-69 yrs: 95% CI = 521-623 meters] In Parkinson disease the goal would be to increase the distance by 86 meters (why 86 meters? because this is the MDC(95). The therapist would have to decide on a reasonable time frame to acheive this goal.
If concern exists about a client falling and you have a Berg Balance Score, we suggest using cutoff scores rather than reference/normative data:
Example of Berg Balance: 40/56 [cutoff of ≤ 45 suggests ↑ fall risk with sensitivity = 64%] OR [cutoff of <50 suggests increase risk with sensitivity = 85%]
To set a goal: Increase Berg Balance from 40 to 50 over the next 6 months (beats the MDC (5 points) and moves the sensitivity to 85%). You could do 40 to 45 to beat the MDC and then do it again to move it to 50. The time frame is up to the therapist.
If concern exists about the client having the endurance to walk in the community use reference data (you can do this with the 6MWT, gait speeds and the Timed Up and Go). For example, in a 6 minute walk test, walking 100 meters with 1 rest [independent community males, 60-69 yrs: 95% CI = 521-623 meters] In Parkinson disease the goal would be to increase the distance by 86 meters (why 86 meters? because this is the MDC(95). The therapist would have to decide on a reasonable time frame to acheive this goal.
If concern exists about a client falling and you have a Berg Balance Score, we suggest using cutoff scores rather than reference/normative data:
Example of Berg Balance: 40/56 [cutoff of ≤ 45 suggests ↑ fall risk with sensitivity = 64%] OR [cutoff of <50 suggests increase risk with sensitivity = 85%]
To set a goal: Increase Berg Balance from 40 to 50 over the next 6 months (beats the MDC (5 points) and moves the sensitivity to 85%). You could do 40 to 45 to beat the MDC and then do it again to move it to 50. The time frame is up to the therapist.
Please click on the buttons below for additional files and tests.