psychometric properties to the Mini-BESTest but has lower sensitivity. Table 5: Clinicometrics of Common Fall Screening Measures in Parkinson’s Disease Tool Cut-off Score (indicating fall risk) Sensitivity Sensitivity Mini-BESTest ≤20 86% 78% Brief-BESTest ≤11 71% 87% TMT ≤21 70% 70% BBS <46 46% 41% TUG 13.5 seconds 39% 87% BESTest = Balance Evaluation Systems Test; TMT = Tinetti Mobility Test; BBS = Berg Balance Scale; TUG = Timed Up and Go Note . From Western Schools, 2018. Balance Balance impairments that are typically assessed in the client with PD are limits of stability, postural response to perturbation, and both static and dynamic balance. As previously mentioned, the Mini-BESTest also assesses balance and has been shown to be a reliable and valid assessment of balance in the PD population (Leddy et al., 2011). This test has subsections for assessing anticipatory and reactive balance control, sensory orientation, and dynamic gait. The TUG and TUG Cognitive are components of the Mini-BESTest. The FGA is an outcome measure derived from the Dynamic Gait Index. Leddy and colleagues (2011) found the FGA to be both reliable and valid for assessing balance in people with PD. In addition, this measure is on the PD EDGE list of recommended measures. These newer measures have not been used as extensively but have the potential to move into widespread clinical use. One of the most commonly used tests for assessing functional balance is the BBS. It has items of static balance (single-limb stance, Romberg); function (sit to stand); and limits of stability (functional reach). The BBS has been shown to have a ceiling effect with people with PD (Tanji et al., 2008), so it may not be appropriate for some individuals with subtle balance problems and was not included on the core set of measures from the PD EDGE taskforce. The Four Square Step Test is a test of coordination and balance while stepping in forward, side-to-side, and backward directions. One study has shown that the Four Square Step Test is not a sensitive predictor of falls among individuals with PD, but the test does allow assessment of an individual’s ability to reverse directions, step over an object, and step sideways and backward (Duncan et al., 2013). Because it is timed, the Four Square Step Test can also be used to measure bradykinesia. Limits of stability can be measured using the Functional Reach Test (Nolan et al., 2010). This test examines an individual’s ability to reach forward and provides some indication of anticipatory balance responses. Static balance is assessed by measuring the time that an individual can maintain single-limb stance, with 60 seconds being a normal score. Another test of static balance is the Romberg Test. The original Romberg Test requires an individual to stand with the feet together, first with eyes open (60 seconds) and then with eyes closed (60 seconds). If the individual’s sway increases or the individual loses balance, balance is deemed to be impaired. There is also a sharpened Romberg Test in which the person stands with one foot in front of the other, with the heel of one foot directly in front of the toes of the other foot. A further progression is the Six- Condition Romberg Test, in which the individual is tested in six progressively more difficult conditions: Romberg stance eyes open, Romberg stance eyes closed, sharpened Romberg stance eyes open, sharpened Romberg stance eyes closed, sharpened Romberg stance eyes open count backward by 3s, and sharpened Romberg stance eyes closed count backward by 3s.
Each position is held for 30 seconds. If a loss of balance occurs, the time to loss of balance is recorded, and the test is stopped without proceeding to the more advanced conditions. The total possible score is 180 seconds. Use of this timed measure allows clinicians to identify the presence of a deficit in static balance and to measure improvement after treatment. Failure before 30 seconds in the eyes-closed condition indicates a problem with proprioception or the vestibular system. Use of the narrowed stance assists in identifying individuals who have subtle problems. Individuals with cerebellar conditions have more difficulty in the narrowed-stance condition, whereas individuals with PD may be able to maintain this position. The addition of counting backward allows clinicians to determine whether balance is affected negatively when the individual is performing two tasks at once, such as walking and talking. Another version of the Romberg Test has 4 conditions, with conditions 1 and 2 being the same as described previously and conditions 3 and 4 involving standing on dense foam with eyes open (3) and closed (4). Failure in condition 4 indicates that the vestibular system is impaired because use of vision and proprioception has been blocked in this condition. Function Functional activity is a broad category, and the various available measures in this category assess different specific elements of functional activity. Given the wide scope of this category, measures should be chosen carefully based on the goals of each individual’s therapy. One measure of functional activity that has been widely used in physical therapy is the Modified Physical Performance Test, which examines mobility, some upper extremity function, and a few ADLs. It is quantifiable, quick, and easy to administer. It does require some standardized testing items that are usually inexpensive to acquire (e.g., bowl, beans, spoon, book, and jacket). There are several self- report measures for ADLs, including the Nottingham Extended Activities of Daily Living Scale, the Older Americans Resources and Services ADL Subscale (OARS), and the MDS-UPDRS ADL Scale. All three scales ask individuals whether they can do the task and how much assistance is needed. Another measure of function is the timed chair rise, which specifically assesses chair to/from standing transfers. There are age-related norms, and the Five Times Sit to Stand Test has been shown to be valid and reliable in PD (Duncan et al., 2011). There are several other versions of this test, including a timed 10-repetition chair rise and a test that measures the number of chair rise repetitions in 30 seconds. Gait is typically measured by timing gait or using measures such as the TMT. Many other functional activities lack any specific outcome measure, and objective measures of these functional activities may be found only within outcome measures that examine multiple domains such as the Modified Physical Performance Test and the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). While stair climbing is assessed within both of these measures, there is a new outcome measure specifically for measuring stair climbing performance: the Step Test, Evaluation of Performance on Stairs (STEPS). It has been shown to be valid and reliable in clients with Huntington’s disease and in older adults (Kloos et al., 2019). STEPS evaluates performance on stairs including safety through observation. STEPS is free for use and can be found at https://hrs.osu.edu/research/research-labs/mend-laboratory/ steps along with instructions and videos. The Modified Physical Performance Test examines multiple domains of function through observation of activities that simulate ADLs, such as time to put on and take off a jacket and time to climb stairs. The OPTIMAL is an instrument that measures difficulty and self-confidence in performing 22 movements that a patient/client needs to accomplish in order to do various functional activities. Participation measures Several quality of life measures have been used in research studies, including the Parkinson’s Disease Questionnaire (PDQ- 39) or its short version (PDQ-8); the World Health Organization Quality of Life Measure (WHOQOL-100) or its short version
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