levodopa because their ability to participate in therapy is best at peak dose, and some functional deficits are more likely to be evident at the end of their dose cycle. Depending on their goals, Outcome measures The use of outcome measures is highly recommended to benefit the individual patient, the community of clients with PD, and providers. Outcome measures establish a baseline status as a means to quantify change in function over time and provide information regarding effectiveness of the care plan as part of periodic re-examination. In addition, they provide the opportunity to collectively compare care across multiple clients with PD to determine an intervention’s effectiveness. Providers benefit as standardized measures provide a common language to evaluate the success of physical therapy interventions, thereby providing a basis for comparing outcomes related to an intervention across clinics. It is important to use the same core measures over the course of the disease for ease in comparison across clinics and in research. The Academy of Neurologic Physical Therapy convened a task force to develop recommendations of outcome measures to be used in the care of clients with PD. The PD Evidence Database to Guide Effectiveness (EDGE) taskforce recommended nine measures as core measures based on the ICF (Table 3). In addition, the task force made recommendations for measures by disease stage, for entry-level education, and for research. The use of these outcome measures also makes it possible to comply with Medicare guidelines for the use of G Codes. The Academy of Neurologic Physical Therapy also underwent an analysis of EDGE task force recommendations across neurologic diagnoses and produced a list of five highly recommended or core outcome measures: 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), BBS, Functional Gait Assessment (FGA), and the Activities-Specific Balance Confidence Scale (ABC). Studies demonstrate that better outcomes of neurologic rehabilitation correlate with use of outcome measures to perform a comprehensive assessment of medical problems, body structure/ 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. 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
clients might come to physical therapy at different times during their medication cycle to address functional limitations during both “on” and “off” times.
Table 3: PD EDGE Recommended Measures Highly Recommended Measures Body Structure and Function MDS-UPDRS – Part 3
Montreal Cognitive Assessment
MDS-UPDRS – Part 1 Activity 6-Minute Walk Test
Functional Gait Assessment
10-Meter Walk Test
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. 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.
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