Parkinson's Disease - Outcome Measures

Original Editor - Bhanu Ramaswamy as part of the APPDE Project

Top Contributors - Wendy Walker, Laura Ritchie, Rachael Lowe, Evan Thomas and Naomi O'Reilly

Physiotherapy Outcome Measures

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
  • Posture
  • Functional performance (including transfers and walking tasks)
  • Fitness and endurance
  • Dexterity and writing
  • Cognition
  • 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.

European Guidelines

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.

PP Parkinsons Outcome Measures.jpg


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 populations 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).

General Principles

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
  • All of the above

Resources

In addition to looking up the instructions and score sheets recommended in the Review version of the European Guidelines, there are several videos capturing the ways to perform the tests.

These videos looks at the gait measure on the UPDRS:

[1]
[2]
[3]

The timed up-and-go (TUG) test can be used to provoke freezing of gait (FOG) in people with Parkinson’s[4] 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?

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References

  1. CurrentProtocols. UPDRS Motor Subscale 3, First Half. Available from: http://www.youtube.com/watch?v=91BZnsm4oHY [last accessed 29/09/16]
  2. CurrentProtocols. UPDRS Motor Subscale 3 Second Half. Available from: http://www.youtube.com/watch?v=EnS4SMQJPKg [last accessed 29/09/16]
  3. Chartered Society of Physiotherapy. The timed up and go test. Available from: http://www.youtube.com/watch?v=lAkVr5l7vOs [last accessed 29/09/16]
  4. 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