Evaluation of the PD patient is focused on determining the patient's functional limitations. Range of motion, strength and balance deficits, postural deviations, general mobility, and level of conditioning are all assessed to determine their contribution to the patient's overall activity level. The evaluation consists of three parts: the history, physical examination, and the functional assessment. This information is then utilized to determine a plan of care (11).
The first component of both the PT and the OT evaluation is to take the history of a PD patient. It is important to determine at what state in the disease process the patient is presenting to the therapist. Information is obtained regarding the patient's ability to perform a variety of functional tasks, including bed mobility, transfers, community ambulation, activities of daily living, work tasks, and recreational tasks. It is important to determine the patient's medication schedule and any on/off fluctuations that may affect exercise performance. An account of freezing episodes, falls or near falls, or any specific situations in which mobility seems to be compromised needs to be noted. Comorbidities such as high blood pressure, heart disease, diabetes, pulmonary problems, cancer history, recent surgical history, depression, and dementia are all factors that affect the patient's ability to participate in a rehabilitation program and must be assessed. It is also important to obtain a complete list of all medications that the patient is taking, not just PD medications, as medication can affect activity performance. During the course of taking the patient's history, the therapist is generally able to determine any barriers the patient may have such as vision deficits, hearing impairment, or cognitive deficits that can affect ability to both learn and perform in a rehabilitation program. It is then crucial to discuss and set the goals of therapy with the patient and family. PD is a progressive condition and, generally, a return to prediagnosis level of function is not possible. The patient should be allowed to identify from their point of view, which deficits they want to improve the most and what level of function they think they can safely and realistically obtain. Whenever possible, the primary caregiver and other family members who are involved in the care of the patient should be engaged in this information gathering stage. Their point of view is often helpful in developing an appropriate rehabilitation program and modification of the patient's activities.
The OT evaluation includes many of the earlier noted elements in the history. The focus of the OT evaluation is to obtain information about specific tasks, requiring upper extremity dexterity for self-care skills and activities of daily living. Specifically, questions regarding level of independence with bathing, dressing, grooming, eating (including swallowing problems and oral control), toileting, functional communication
(telephone use, writing, and keyboarding), housekeeping activities, cooking, driving, shopping, and work activities requiring upper extremity coordination (1,2,11).
Sitting and standing posture are observed with attention to trunk flexion, forward head, or uneven lower extremity weight-bearing. Postural deficits alter the body's center of gravity during movement. Postural deficits also create muscle imbalances due to overly tight and overly stretched muscles that can contribute additional impairment to the rigidity and weakness, usually accompanying PD.
The range of movements of all extremity joints, as well as the cervical and lumbar spine, are observed with the deficits or asymmetries recorded. A therapist will often use a goniometer and/or inclinometer to record exact range of motion (ROM). Precise measurements allow the clinician to establish a baseline to record improvement or disease progression. Flexibility is assessed with particular attention to large muscle groups such as the hamstrings, hip flexors, gastrocnemius-soleus complex, and the pelvic and shoulder girdle muscles (1).
Manual muscle testing is performed for all major muscle groups of the extremities, cervical spine, and core stabilization musculature. Weakness in PD patients tends to be due to deconditioning and other comorbidities.
The patient's overall ability to move in a functional manner is recorded. In patients with PD, turning in bed, supine-to-sit and sit-to-stand transfers tend to be particularly difficult. Observation of rigidity patterns and loss of segmental movement are often noted with bed mobility. Difficulties with supine-to-sit transfer can result from core muscle group weakness, whereas sit-to-stand transfers can be compromised by inefficiency in shifting the center of gravity forward during the movement sequence.
Gait is evaluated on a level surface and, if possible, without the support device the patient may be using. Careful attention is paid to any postural changes, contributing to deviations in gait mechanics, deficits in dynamic balance, or safety with walking. The kinematics of the patient's gait cycle is compared to normal standards and deviations are objectively recorded. It is possible to quantify elements of a patient's gait by measuring velocity (i.e., time to cover a fixed distance) and stride length (i.e., number of steps taken over a fixed distance). If safe and appropriate, it is also important to observe the patient negotiate stairs, curbs, inclines, and uneven surfaces.
Visser et al. (12) found the retropulsion test recommended by Nutt et al. (13) to be the best evaluation procedure for postural instability. The examiner stands behind the patient and, after an explanation and practice test, the patient is jerked backward by the shoulders. A normal test is taking a step or two backwards to correct. Several steps backwards or a fall into the examiner is defined as a balance deficit. Static balance can also be quantified by timing the patient's ability to stand on one leg. A less objective but sometimes utilized method is to simply challenge the patient's static balance in a random series of pushes or pulls on the patient's shoulders, as they sit and stand. Dynamic balance can be assessed in a number of ways, including challenges to the patient's center of gravity such as high knee walking, heel walking, toe walking, tandem walking, and a carioca or "braiding" side step.
There are a number of simple tests utilized to assess coordination of movement. Finger to nose, pronation/supination of the wrists, tapping the hand on the knee, alternate heel to knee, and drawing a circle in the air are a few of the maneuvers observed and rated on their difficulty of performance.
A thorough palpatory examination of the musculature should be performed noting muscle tone and areas of pain. Other elements of the evaluation that should be assessed include inspection of the skin paying close attention to friction abrasions or bruising from falls, sensory testing, and deep tendon reflex testing.
The OT evaluation of the PD patient includes some of the same elements as noted for physical therapy. The focus in OT is generally on upper extremity coordination and control and in the context of activities of daily living and self-care activities (14).
ROM of the upper extremity and shoulder girdle are assessed. Cervical ROM is evaluated, as it may directly affect the patient's ability to focus visually on the tasks they are performing. In addition to routine upper limb strength testing, grip and pinch dynamometer measurements are also made.
In addition to the upper extremity coordination maneuvers described in the PT evaluation, an occupational therapist may utilize standardized tests of fine motor hand coordination, such as the Jebsen-Taylor Hand Function test, the Minnesota Rate of Manipulation test, and the Purdue Pegboard test (11).
In this portion of the examination, a sample of activities of daily living and functional use of the upper extremities are actually simulated and performed by the patient. As the patient performs writing tasks, manipulates eating utensils, or puts on an article of clothing for example, careful attention to tremor, quality of movement, speed of performing tasks, and proficiency are recorded.
Once the evaluations are completed, a detailed problem list is derived and specific deficits that can be addressed with a rehabilitative treatment plan are outlined. Many underlying causes such as trunk rigidity, inflexibility, postural deviations, balance deficits, diminished fine motor control, core weakness, and general deconditioning can be used to develop a patient specific exercise and educational program. The treatment plan must contain both short- and long-term treatment goals. The problem list and goals help structure the exercise routine, the functional adaptations, patient and family education, and treatment strategies to be utilized, as the patient progresses through the short-term goals to the desired treatment outcome and long-term goal attainment at the time of discharge from therapy.
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