Musculoskeletal system Muscle rigidity and postural changes can make people with PD particularly susceptible to muscle shortening and ROM issues leading to contracture. Specific muscle groups (flexors and rotators) are especially prone to shortening. Assess the length of the pectoralis muscles, iliopsoas, hamstrings, and gastrocnemius muscles. Range of motion of the trunk and extremities is assessed periodically, with special attention paid to trunk extension, shoulder elevation/abduction, hip extension, knee extension, ankle dorsiflexion, and trunk and neck rotation. Additionally, the client should be examined for scoliosis as this typically occurs in later stages of the disease. The easiest way for the clinician to assess trunk rotation safely is to examine the individual’s ability to rotate while seated with feet on the floor and arms crossed. To perform this assessment, the therapist instructs the individual to look back over his or her shoulder, and the therapist notes any side-to-side asymmetry. If a standard seat and location are used, the therapist can measure rotation by placing numbers on the wall at 1-inch intervals and asking the individual to indicate the last number that can be read. Trunk rotation is the key to many functional activities such as walking with long strides and reaching. Evans and colleagues (2006) describe another method. A line is marked on the floor using tape, and a series of pairs of different-colored points are marked on the tape, equidistant from the center mark on both the left and the right side. Subjects stand (or sit) on the line with their feet shoulder-width apart, using the points as a guide to ensure that their feet are placed symmetrically on either side of the center mark. A wooden bar, approximately 4 feet long, is placed evenly across the subject’s shoulders and held in the subject’s hands, which rest as close to the shoulders as is comfortable. Subjects are told to rotate as far as possible to the left or right, keeping the bar resting on their shoulders and not moving their feet. The therapist should check that the bar remains horizontal throughout the test. At the end of the rotation movement, a plumb bob or other weighted object on a string is attached to the left end of the bar for right rotation and the right end of the bar for left rotation. The rater steadies the bar and then the bob is allowed to drop to touch the floor. A nonpermanent marker pen is used to indicate where the plumb bob touches the floor. A long-armed goniometer is used to measure degrees of rotation. The axis of the goniometer is placed on the center of the line, and the stationary arm is placed along the line. A ruler or other lightweight long stick can be secured to the moving arm of the goniometer to reach the mark and allow for more accurate measurement. In a clinic that takes these measurements frequently, a circle can be marked on the floor with the degrees marked along its arc at regular intervals; the therapist can simply take the measurement from the marks on the circle rather than use the goniometer every time. neurologic disorders and makes recommendations regarding best measures for therapist use in the clinic and research environments. These are known as the EDGE documents . The neurology section has completed EDGE recommendations for stroke, multiple sclerosis, traumatic brain injury, spinal cord injury, PD, and vestibular dysfunction. The PD EDGE document is posted on the website of the APTA Academy of Neurologic Physical Therapy at http://www.neuropt.org. There is a set of core outcome measures recommended by the Academy of Neurologic Physical Therapy to use across all neurologic disorders. This includes the BBS, FGA, Activities-Specific Balance Confidence Scale, 10-Meter Walk Test, 6-Minute Walk Test, and the Five Times Sit to Stand Test. second) is highly predictive of many health outcomes such as ability of the elderly to ambulate in the community (Elbers et al., 2013) and likelihood of hospitalization or death in the next year (Cesari et al., 2005). In addition, those with walking speeds between 0.4 and 0.8 m/s have limited ability to ambulate in
Dyskinesia : The assessment should include information about whether dyskinesias are present and if they are bothersome to the client or interfere with the client’s ability to participate in the examination process in any way. If dyskinesias are present and bothersome, note and consider timing of medications. Freezing : Freezing and difficulty initiating movement are debilitating problems and a major cause of disability and falls in PD. These symptoms can be difficult to elicit in the clinic. There is new evidence that the most effective way to elicit freezing is a rapid 360° turn in both directions (Snijders et al., 2012). Freezing can also be assessed by observing gait in a confined space and having the individual walk into a corner and then turn. However, this will not always elicit freezing, even in individuals with severe freezing of gait. The therapist should also take a history of frequency of freezing and typical triggers of freezing episodes. The only validated outcome measure is the Freezing of Gait Questionnaire. There are six items regarding gait and how freezing affects the ability to walk during normal daily activities. The scale ranges from 0, which denotes normal movement, to 4, which indicates an inability to walk (Giladi et al., 2009). The maximum total score possible is 24, with higher scores meaning more severe freezing of gait. The questionnaire has excellent intra-rater and test-retest reliability (Giladi et al., 2009). It is a more sensitive measure of freezing of gait than the freezing- while-walking item on the MDS-UPDRS, which simply asks the person to rate the freezing as none, rare, occasional, frequent, or frequent falls with freezing (Giladi et al., 2009). Newer studies are examining the use of sensors to detect and measure freezing of gait, but at this time these are not applicable to the clinic setting (Pardoel et al., 2019). Another emerging method of assessment is measuring the duration of freezing during dual task performance (Herman et al., 2020). The client performs usual single task gait, dual task gait (walking while carrying a tray), and triple task gait (walking while carrying a tray and subtracting 7s). Freezing of gait is scored using usual measures, and the total time frozen is obtained (Herman et al., 2020). Movement scale : Rapid, repetitive, finger-to-finger movement is a means to assess for movement scale (size or scope of movement) or the presence of hypokinesia and coordination. Instruct the client to touch the index finger to the thumb repetitively, opening the hand fully each time while the therapist observes speed, scale, and smoothness of the finger-to-finger movement for 30 seconds. For an individual with PD, finger-to- finger movements will get progressively smaller the longer the individual does the movement; the movements are slow, with irregular timing of the motions occurring later in the disease process. Functional losses and impact on participation Measuring function at the beginning and the end of treatment is a means of demonstrating that therapy has led to meaningful changes that will improve the individual’s ability to remain independent and active. The use of standardized measures establishes a baseline status and provides a means of quantifying change in status throughout and at the end of the episode of care. The use of standardized measures improves communication because a common language allows comparison across therapists and clinics. The use of standardized measures also allows clinicians to better gauge the effectiveness of interventions in the clinical setting. The neurology section of the American Physical Therapy Association (APTA) systematically examines standard outcome measures across common Gait measures One of the easiest and most powerful measures of walking ability is gait speed. Studies have shown that gait speed can be correlated with both function and health outcomes in the elderly and those with PD (Cesari et al., 2005; Elbers et al., 2013). As shown in Table 4, gait speed greater than 0.8 m/s (meters per
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