function and participation, and use of the initial evaluation to initiate planning for discharge needs. This course will now
discuss examination techniques and outcome measures across all levels of the ICF in PD.
Table 3: PD EDGE Recommended Measures Highly Recommended Measures
Body Structure and Function Montreal Cognitive Assessment
MDS-UPDRS – Part 3 MDS-UPDRS – Part 1
Activity
6-Minute Walk Test 10-Meter Walk Test
Functional Gait Assessment Five times Sit to Stand Test
Mini-BESTest
9-Hole Peg Test
MDS-UPDRS – Part 2
Participation
PDQ-8 or PDQ-39 Recommended Measures for Specific Constructs Freezing of gait
Fatigue
Freezing of Gait Questionnaire
Parkinson’s Fatigue Scale
Fear of falling Dual task Activities-Specific Balance Confidences Scale Timed Up and Go Cognitive (part of the Mini-BESTest)
PD EDGE = Parkinson’s disease Evidence Database to Guide Effectiveness; MDS-UPDRS = Movement Disorder Society-Unified Parkinson’s Disease Rating Scale; BESTest = Balance Evaluation Systems Test; PDQ = Parkinson’s Disease Questionnaire
Note . From Western Schools, 2018. Bodily structure and function
The examination begins with a systems review to screen for problems in all the major body systems. Thoroughly examine any system in which a deficit is noted. In individuals with PD, it is important to thoroughly examine the cardiovascular, musculoskeletal, and neurologic systems. This section details key examination techniques to consider when examining a client with PD. Individuals with PD have autonomic dysfunction that most commonly leads to problems related to orthostatic hypotension. The physical therapist needs to assess and document blood pressure response to position changes in these individuals. Measure blood pressure to assess for orthostatic hypotension: first when the patient is supine, then while sitting, and last while standing. Take each measurement 3 minutes after the person has changed position. If there is a pressure drop of at least 20 mmHg in systolic or 10 mmHg in diastolic pressure, it is reasonable to conclude that the individual has orthostatic hypotension because of autonomic dysfunction. In contrast, blood pressure changes that occur immediately and resolve in less than 3 minutes are likely because of sluggish reflexes associated with the aging process. The physical therapist should screen strength of the major muscle groups of the upper and lower extremities and of the trunk, including a screen of strength of the trunk extensors. Significant deficits in muscle strength may indicate the presence of a secondary diagnosis because strength, as tested by the manual muscle test, is usually not compromised until late in the course of PD. Other parkinsonian syndromes that can lead to declines in strength are multiple system atrophy and vascular PD. The key problems involving speech that are found with PD are bradykinesia, hypophonia, monopitch, spastic speech, ataxic speech, and rushes of speech. Bradykinetic speech is slow speech, and in PD it may also be accompanied by difficulties in initiating speech or long pauses before beginning to talk in a conversation. Hypophonia is soft speech caused by poor coordination of the vocal cords. Additionally, speech is typically monotone or monopitched and may be ataxic, with decreased coordination of speech and breathing resulting in increased rate of speech, decreased volume, and a harsh voice. Bradykinetic speech is measured by testing reading speed. If deficits are
noted, speech therapy can be recommended to improve volume and speed. Neurologic system Every examination of the client with PD should include routine neurological tests such as proprioception, sensation, reflexes, and tone. However, there are additional neurological impairments to assess in the client with PD. The MDS-UPDRS and the PD-PROFILE (Schenkman et al., 2010) include scales for both the clinician and patient self-report and are useful for gathering information on impairments of body structures such as rigidity, tremor, and bradykinesia. Both tools also include items that address limitations at the activity level. Bradykinesia : To assess bradykinesia, the MDS-UPDRS includes “finger tapping,” which is a rapid, repetitive, index finger-to- thumb movement. The client is instructed to repetitively touch the index finger to the thumb, opening the hand fully each time while the therapist observes speed, amplitude, hesitations, halts, and decrementing amplitude on each side separately for 10 repetitions. It is scored with 0 (no problems), 1 (mild), 2 (moderate), 3 (severe), or 4 (cannot or can barely perform task). Further descriptors for each category are included in the test. Bradykinesia of the lower extremity can be assessed using the same scale but with toe tapping while keeping the heel on the floor. Balance : The Pull Test (which appears in both the MDS-UPDRS and the PD-PROFILE) is a test for postural instability. Instruct the patient to stand with the feet shoulder-width apart and to do whatever he or she needs to do to prevent falling. The examiner stands behind the patient and without warning grabs both shoulders and pulls backward quickly. The therapist should stand behind the patient, an arm’s-length away with feet spread shoulder-width apart to prevent a fall. This test is scored from 0 to 4, with 0 being a normal response of 0 to 3 steps and no loss of balance, and 4 being unable to stand unassisted. Tremor : Tremor should be described in terms of location (upper extremity, lower extremity, lip/jaw) and amplitude and constancy (<25% of exam period, 26 to 50% of exam period, 51 to 75% of exam period, >75% of exam period). Note whether other types of tremor (postural or kinetic) are present.
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