Parkinson's - Physiotherapy Referral and Assessment
- 1 Introduction
- 2 Assessment
- 3 Disease Progression
- 4 Outcome Measures
- 5 References
Physiotherapists play a vital role in supporting people with Parkinson’s to choose management strategies, prioritize and address the challenges they face over the course of the condition. Improving movement and safety is usually the main focus of physiotherapy in light of the progressive pathology and the disability and participation restrictions this can cause.
The American Academy of Neurology recommend the clinicians discuss the clinical presentations of the individual with Parkinson’s at least once yearly with a physiotherapist to consider when would be an optimal time to refer the person for physiotherapy services. An ideal best practice standard would be for the physiotherapist to have Parkinson’s expertise, and to be involved at the point of diagnosis. This does not always occur and until such time as we are referred all people with Parkinson’s, some referral criteria have been agreed.
Physiotherapy assessment considers ways in which the condition is affecting the individual with Parkinson’s, whilst being aware of the impact on close carers and relatives, especially when someone is newly diagnosed or has been diagnosed for some time.
The history taking and physical assessment aspects of the assessment enable an honest discussion of what is realistic of the things the person wants to do. The core areas of physiotherapy interventions for which there is evidence of effectiveness for people with Parkinson’s are:
It is known that people with Parkinson’s are less active than their peers as the condition progresses, resulting in muscle weakness and power, increased falls risk and reduced walking speed, itself an indication of reduced life expectancy. Physiotherapist must understand the importance of education on staying active and develop a management plan that tackles all physical problems that result in reduced activity levels.
Difficulties arise for people with Parkinson’s due to the complexity of changing position – e.g. rising from lying or sitting, turning activities
These become difficulty due to the combination of sequential sub-tasks, dexterity and co-ordination requirements
Quality of Movement
Parkinson's is associated with different movement patterns which are associated with functional decline on the long-term:
- Dyskinesia : rapid, random, jerky movement
- Freezing: where the person cannot move – either to start a movement (or speech), or where they come to a halt
- Festinaton: involuntary gait quickening
- Dystonia: sustained muscle contractions (can cause abnormal postures and be painful)
- Falling: often during complex movement e.g.turning, or misjudging clearance.
- Bradykinesia: longer latencies for muscle force production and relaxation, initially affecting power and strength
Varied postural changes are common among people with Parkinson's including:
- Camptocormia: an involuntary forward flexion (usually greater than 45°) when person is upright, that reduces/ disappears when the person lies down.
- Antecollis: forward flexion of head and neck
- Pisa syndrome: a sustained lateral flexion of the trunk; not necessarily to the Parkinson’s dominant side
postural flexion changes affect the quality of life and make people more prone to vertebral fractures.
Balance and Falls
Balance impairment and falls (30-70% of people with Parkinson's experience falls) are common problems for people with Parkinson’s; these problems often start after about 5 years of diagnosis due to worsening of the systems that maintain body position, the progressive slowness of movement, trunk rigidity and reduced proprioception.
The following factors are considered to be risk factors and predictors of falls in PD:
- Time since Parkinson’s onset,
- Associated neuro-musculo-skeletal changes
- Reduced leg muscle strength
- Proprioception and gait speed changes
- Increased gait variability
- Freezing of gait
A thorough assessment of each possible factor contributing to the likelihood of falls is essential, putting in mind other factors such as cognition and strategy selection, quality of life misjudgment and distraction, fear of falling, personal factors and environment. Considering different factors when designing a rehabilitation program should yield positive outcomes and reduce the risk of falls.
Falling has wide ranging impact including risk of fractures (especially hips and wrist), carer stress and fear of movement.
People with Parkinson's require assessment of continuous or episodic problems with gait.
Impaired speed-distance and amplitude scaling; inadequate burst duration and reduced burst amplitude result in walking slower.
Freezing of gait (FOG) is a common problem associated with Parkinson's. It is defined as '' an episodic absence or marked reduction of forward progression of the feet despite the intention to walk'' and is considered to increase an individual's falls risk. Recent research suggests that FOG reflects a "sudden derangement of locomotor network dynamics." It tends to be triggered by increased cognitive load, such as multi-tasking, or stressful situations. It may disappear if the person is paying extra attention to their gait hence it is challenging to assess FOG in clinical situations.
Festination is defined as ''the tendency to move forward with increasingly rapid, but ever smaller steps and is frequently present in patients with FOG''
Assessment of FOG and festination relies mainly on subjective description of the patient and/or a caregiver. It is important to describe and define FOG and festination clearly to the patient in order to clarify the symptoms and you may have to demonstrate what they look like by showing videos of FOG and festination variants. Asking about the effect of medication is helpful to measure the responsiveness to levodopa. It is also recommended to ask about history of falls and find if there is fear of falls. The unified Parkinson’s disease rating scale and the Movement Disorder Society-UPDRS (UPDRS Part II, item 13 include questions on FOG and should give the examiner an idea on how FOG is affecting the daily living.
You can also ask your patient to keep a diary to describe FOG behavior to give you an idea of frequency of the episodes, time of day, triggering circumstances and associated falls or a near-fall. This will help you in designing appropriate rehabilitation measures.
Patients with Parkinson's may experience respiratory symptoms to varying degrees. The underlying mechanism for respiratory disease in Parkinson's is not known, but dysfunction may be due to:
- Restrictive changes
- Upper airway obstruction
- Abnormal ventilatory drive
- Response to medications
Respiratory problems associated with Parkinson's may require acute care intervention. Shortness of breath on exertion is reported by 35.8% of Parkinson's patients. Cough and sputum production were reported by 17. 9% and 13% of patients, respectively. Whenever a symptom of ventilatory dysfunction is present, pulmonary function test is recommended to identify the dimensions of the problem and tackle it with a proper care plan.
Pain is a multi-dimensional phenomenon and is experienced by the majority of people who have Parkinson's - 30 to 50% of people with Parkinson's experience pain mainly musculoskeletal pain in the neck, arm, paraspinal or calf muscles. MSK pain is more likely to be caused by rigidity. Radicular and neuropathic pain are experienced by 5-20% of people with Parkinson's. Dystonic pain, restless leg syndrome and akathisia were reported to be associated with Parkinson's. Pain is present at all stages of Parkinson's, including as a premotor symptom. It is thought that both nigral and extra-nigral pathology may result in abnormal processing in the medial and lateral pain systems of patients with Parkinson's. Pain can be assessed using different measuring scales and questionnaires and these should be included in the management plan.
As the condition progresses, the individual’s needs, and our physiotherapy goals will alter; it is essential that the person is reviewed regularly.
In the early stages of the condition, physiotherapy assessment should aim to support educational needs e.g. about keeping fit, active and healthy, and on minimizing the impact of Parkinson’s on people’s lives. As Parkinson’s progresses and the individual experiences problems with their movement, the assessment focus moves towards a review of physical activity and mobility, possibly assessing for the optimal movement and cognitive strategies.
In the later stages, as the condition progresses, many of the symptoms of Parkinson’s have a bigger impact on daily life, often mixing with other medical conditions. Physiotherapy assessment focuses on decisions about how to cope with these changes with an emphasis on a support network to best keep the person active and safe when moving.
In terms of an easy access on-line resource, we advise to you to read the Review version of the European Physiotherapy Guideline for Parkinson’s. Although the title intimates ‘European’, the evidence informing the document is taken from international studies and input from worldwide experts. The Guideline is an update of the first evidence-based guideline with practice recommendations for physiotherapy in Parkinsons’s was published by the Royal Dutch society for Physical Therapy (KNGF), the ‘Dutch Guidelines’..
The Association of Physiotherapists in Parkinson's Europe (APPDE) requested the update, the KNGF agreed with ParkinsonNet (a community of healthcare professionals specialised in Parkinson's) to update and adapt the guideline into a European guideline for physiotherapy in Parkinson’s. The development is endorsed by the APPDE, the European Region of the World Confederation for Physical Therapy (ER-WCPT) the European Parkinson’s Disease Association (EPDA). Nineteen member organisations of the ER-WCPT as well as people with Parkinson’s and their representatives participated in the development process of the European Guideline. The classification system of the International Classification of Functioning, Disability and Health (ICF classification) is used. This framework provides a common language and basis for understanding and describing health and health-related problems. The aim of using this common language is to improve communication about functioning of individuals with Parkinson’s between health and social care workers, researchers and social policy makers.
The Guideline is intended to be helpful to “all involved in Parkinson care who, supporting evidence-based, patient centred care", and therefore has been divided into four parts:
- The Guideline, mainly for physiotherapists. This is the one we refer to in this Project and included the background on Parkinson's and health management, physiotherapy core areas and rationale and evidence for categories of interventions
- Information for people with Parkinson's: Includes self-management support and how to get the best out of physiotherapy care
- Information for clinicians: when to refer to physiotherapy and what to expect
- Information to the development and scientific justification of the Guideline: insight in the barriers and facilitators of current care and details to measurement tools and the GRADE-based recommendations
In the Guideline
- Appendix 4 on page 104 provides an ICF assessment and report form; Appendix 9 on page 155 provides a list of Parkinson’s-related ICF domains, and Appendix 10 on page 156 provides the most appropriate measurement tools validated with Parkinson’s populations according to the ICF domains.
- Chapter 4 (pages 32 - 41) concentrates on the core areas of physiotherapy for people with Parkinson’s
- Chapter 5 (pages 42 - 63) is on history taking and physical examination
- Chapter 6 (pages 64 – 91) provides ideas on the rationale and evidence for physiotherapy interventions
Physiotherapy standards usually recommend the use of an outcome measure to evaluate a change in a person’s status, as well as monitor the outcome of a clinician’s chosen intervention (for effectiveness of treatment).
There exists a wide range of measures, whether to record assessment markers or to measure outcome of intervention. The history you take about the person, their reported problems and expectations from physiotherapy should indicate the tool you choose to record baseline assessment, or to measure change following agreed intervention.
For example, you might measure:
- Condition status
- Quality/safety of walking
- Balance, falls risk and confidence to move
- Functional performance (including transfers and walking tasks)
- Fitness and endurance
- Dexterity and writing
- Quality of life
- Respiratory function
If a person does not score well in a specific category of the tool, for example in the 'step length' component in a gait assessment, or the 'sit to stand' component of a balance assessment, you can use this as an outcome indicator at the end of your interventions. This will allow you to measure change in their ability in that specific domain.
To measure the range of what a physiotherapist treats, you need to use more than one measurement tool.
The Review version of the European Physiotherapy Guideline for Parkinson’s Disease recommend tools for consideration when assessing people with Parkinson’s. Appendix 10 (page 96 onwards) provides the forms to print out with instruction and scoring sheet, and Appendix 11 (page 128) divides the tools into the domains of the International Classification of Functioning they best represent.
You might not see a tool you use regularly in the above list. Many well-known tools were developed to ensure reliable recording for research purposes – they do not always make good tools to use in clinical practice, and are of a mixed nature in terms of the ICF domains.This makes it difficult to understand what aspect of the impairment or disability we have had most impact on. The European Guideline recommends tools that are quick to use in practice and that have had reliability and validity tested.
Appendix 5 (page 105 onwards) provides the forms to print out with instruction and scoring sheet, and Appendix 10 on page 156 provides the most appropriate measurement tools validated with Parkinson’s according to the ICF domains.
Many scales were not developed for research, but established and tested having arisen from expert clinical practice, hence are still relevant for use clinically. You can find details of the entire list of measurement tools considered and why they were excluded from the main Guideline e.g. the Lindop Scale in the section on Development and scientific justification.
The European Guideline also suggests a form is posted to the person’s house prior to their appointment, or that on the first appointment they attend a few minutes early to fill in this Pre-assessment Information form (PIF) in Appendix 2.
As with the Dutch Guidelines, a set of four Quick Reference Cards (QRC) have been provided that summarise information physiotherapists might need when considering the best way to take history (QRC 1); Physical examination (QRC 2); specific treatment goals and interventions (QRC 3) and GRADE-based recommendations (QRC 4) (pages 188 – 191).
Whilst an assessment tool or measure may indicate a problem area and provide an objective marker, it cannot replace a therapist’s skill in observing the cause of the problem.
Take for example, the Chair Stand Test, designed to test the functional fitness (of seniors) and a good measure of leg strength and endurance. The procedure follows a protocol with a standard height test, starting position and a count of how many times the person can stand completely up, then completely back down over a 30 second period.
Your assessment should differentiate whether the person with Parkinson’s does or does not manage the test well, based on:
- Muscle weakness
- Problems due to bradykinesia or rigidity
- Limited flexibility preventing range of movement into forward lean
- Fear of coming too far forward in case they fall as they stand
The timed up-and-go (TUG) test can be used to provoke freezing of gait (FOG) in people with Parkinson’s Problems are recorded on a digital video camera to permit clinical analysis. Other considerations when measuring a person’s ability is the safety aspect. Someone soon after diagnosis, and several years following diagnosis may do well with a test such as the Timed up and go. Consider whether it is still an appropriate tool when they are entering the stage where they repeatedly fall, or freeze, especially on turning – do you need to measure how quickly they can complete a test if it compromises safety?
- Parkinson's - Clinical Presentation
- Parkinson's - Anatomy, Pathology, Prognosis and Diagnosis
- Physiotherapy - Management and Interventions
- Key Evidence and resources
- Parkinson's UK. Parkinson's walking tips. Available from: https://www.youtube.com/watch?v=CFhyigIHYKw
- TheLancetTV. Freezing of gait. Available from: https://www.youtube.com/watch?v=3-wrNhyVTNE
- jadedonefl. Parkinson's and dystonia-Walking. Available from: https://www.youtube.com/watch?v=q_KOeCxRxxI
- Paul SS, Allen NE, Sherrington C, Heller G, Fung VS, Close JC, Lord SR, Canning CG. Risk factors for frequent falls in people with Parkinson's. Journal of Parkinson's. 2014 Jan 1;4(4):699-703.
- Hulbert S, Rochester L, Nieuwboer A, Goodwin V, Fitton C, Chivers-Seymour K, Ashburn A. Staying safe”–a narrative review of falls prevention in people with Parkinson’s–“PDSAFE. Disability and rehabilitation. 2018 May 11:1-0.
- Barthel C, Mallia E, Debû B, Bloem BR, Ferraye MU. The practicalities of assessing freezing of gait. Journal of Parkinson's. 2016 Jan 1;6(4):667-74.
- Pozzi NG, Canessa A, Palmisano C, Brumberg J, Steigerwald F, Reich MM et al. Freezing of gait in Parkinson’s disease reflects a sudden derangement of locomotor network dynamics, Brain. 2019; 142(7):2037-50.
- Parkinsonian Gait Video. Available from: https://www.youtube.com/watch?v=B5hrxKe2nP8
- Torsney KM, Forsyth D. Respiratory dysfunction in Parkinson's disease. J R Coll Physicians Edinb. 2017;47(1):35-9.
- O’Callaghan A, Walker R. A review of pulmonary function in Parkinson’s disease. Journal of Parkinsonism and Restless Legs Syndrome. 2018 Jan 1;8:13-23.
- Lee MA, Prentice WM, Hildreth AJ, Walker RW. Measuring symptom load in Idiopathic Parkinson's. Parkinsonism & related disorders. 2007 Jul 1;13(5):284-9.
- Blanchet PJ, Brefel-Courbon C. Chronic pain and pain processing in Parkinson's disease. Prog Neuropsychopharmacol Biol Psychiatry. 2018;87(Pt B):200-6.
- Beiske AG, Loge JH, Rønningen A, Svensson E. Pain in Parkinson’s disease: prevalence and characteristics. Pain 2009;141:173e7.
- CurrentProtocols. UPDRS Motor Subscale 3, First Half. Available from: http://www.youtube.com/watch?v=91BZnsm4oHY [last accessed 29/09/16]
- CurrentProtocols. UPDRS Motor Subscale 3 Second Half. Available from: http://www.youtube.com/watch?v=EnS4SMQJPKg [last accessed 29/09/16]
- Chartered Society of Physiotherapy. The timed up and go test. Available from: http://www.youtube.com/watch?v=lAkVr5l7vOs [last accessed 29/09/16]
- Morris TR, et al. Clinical assessment of freezing of gait in Parkinson’s disease from computer-generated animation. Gait Posture (2013) http://dx.doi.org/10.1016/j.gaitpost.2012.12.011
- Invigorate Physical Therapy and Wellness. What does dyskinesia look like in Parkinson’s?. Available from: https://www.youtube.com/watch?v=ig0kvDAB3eA
- Stanford Medicine 25. Approach to the Exam for Parkinson'sAvailable from: https://www.youtube.com/watch?v=cxHpFWKIfGw
- UMHealthSystem. Parkinson's - Balance, Falls & Cognition: Roger Albin. Available from: http://www.youtube.com/watch?v=NtMri6DzltU [last accessed 29/09/16]