2/2/2014 TAKING THE STEP OVER THE EDGE: HOW TO APPLY THE RECOMMENDATIONS FOR USE OF OUTCOME MEASURES IN PD OBJECTIVES PDEDGE PROCESS

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1 TAKING THE STEP OVER THE EDGE: HOW TO APPLY THE RECOMMENDATIONS FOR USE OF OUTCOME MEASURES IN PD Task force Chair: Deb Kegelmeyer, PT, DPT, MS, GCS; Members: Terry Ellis PT, PhD, NCS, Alicia Esposito PT, DPT, NCS, Rosemary Gallagher PT, DPT, GCS PhD(c), Cathy C. Harro MS, PT, NCS, Jeffrey Hoder PT, DPT, NCS, Erin Hussey DPT, MS, NCS, Suzanne O Neal, PT, DPT, NCS OBJECTIVES To evaluate the various outcome measures that have been utilized within clinical care and across research studies for people with Parkinson s disease. To determine a core set of outcome measures that could be utilized by clinicians across the continuum of care and for clinicians and researchers across the stages of disease progression. To present these core measures through clinical cases crossing disease stages with recommendations to support their use to measure change as well as guide clinical decision making. 2 USING OUTCOMES TO GUIDE INTERVENTION PDEDGE PROCESS Individual patient: Establishes baseline status as a means to quantify change in function Provides information about effectiveness of care plan as part of periodic re-examination Patients as a cohort: Provides the opportunity to collectively compare care to determine an intervention s effectiveness Providers: Provides a common language to evaluate the success of physical therapy interventions, thereby providing a basis for comparing outcomes related to an intervention across clinics 3 Initial review of psychometric properties of each of 62 selected measures by 2 task force members Recommendations for use of an outcome measure were rated on a 4 point ordinal scale 4 Highly Recommend excellent psychometrics in target population (e.g. valid and reliable with available data to guide interpretation) AND excellent clinical utility (e.g. administration is < 20 minutes, requires equipment typically found in the clinic, no copyright payment required, easy to score) 3 Recommend good- psychometrics (may lack information about reliability, validity, or available data to 2 Reasonable to use, but limited study in target group 1 Do not Recommend guide interpretation) in target population AND good clinical utility (e.g. administration/scoring > 20 minutes, may require additional equipment to purchase or construct) good or excellent psychometric data demonstrated in at least one population*, but insufficient study in target population to support a stronger recommendation (does not have any negative psychometric data) good clinical utility (e.g. administration/scoring > 20 minutes, may require additional equipment to purchase or construct) No negative psychometric data. poor psychometrics (inadequate reliability or validity) OR limited clinical utility (extensive testing time, unusual or expensive equipment, ongoing costs to administer, etc.) A modified Delphi process used by the entire task force to reach a consensus regarding the final recommendations 4 PARKINSON EDGE MEASURES REVIEWED PARKINSON EDGE MEASURES REVIEWED Body Structure/Function Body Function/Activity Activity Level/Balance Function Activity Level/Gait & Mobility Montreal Cognitive Assessment MDS UPDRS (Part 1 & 3) Parkinson s Fatigue Scale MDS UPDRS (Part II) Nine Hole Peg Test Five Times Sit to Stand Mini BEST Functional Gait Assessment Activities Specific Balance Confidence Scale 10 Meter Walk Test 6 Minute Walk Test Freezing of Gait Questionnaire Timed Up & Go Cognitive Participation Level PDQ 39 & PDQ 8 1

2 RECOMMENDATIONS CORE MEASURES The task force made recommendations for the following: Outcome measures for each Hoehn and Yahr stage Measures that should be taught in entry-level programs Review of measures with comments on use in research Assessment establishes a baseline that can also be compared to normative data time of diagnosis periodically through even the early stages a It is important to use the same CORE measures over the course of the disease for ease in comparing across clinics and in research. Therefore, the PD EDGE taskforce has strived to come up with valid and clinically useful set of CORE measures to recommend for use in all clinics across the entire spectrum of care in PD. CSM Highly recommended measures: Body Structure and Function MDS-UPDRS revision* - part 3 MDS-UPDRS part 1 Activity 6minutewalk 10 meter walk Mini BESTest MDS-UPDRS part 2 Participation PDQ-8 or PDQ-39 Montreal Cognitive Assessment Functional Gait Assessment Sit to stand 5 times 9 hole peg test All measures in the highly recommended category are also recommended for use in research and students learn to administer. * recommend students exposed Recommended Measures for Specific Constructs Freezing of Gait Freezing of Gait questionnaire Fatigue Parkinson's Fatigue Scale Fear of falling ABC scale Dual Task Timed Up and Go cognitive 9 MEASURES WITH G CODE RECOMMENDATIONS Outcome Measure Mobility: walking & moving around G Code Use Changing & maintaining body position Carrying, moving & handling objects 5 Time Sit to Stand 6 Minute Walk 9 Hole Peg Test 10 Meter Walk Mini BESTest Functional gait assessment Self care 10 OUTCOME MEASURE TO INTERVENTION Studies demonstrate better outcomes of neurologic rehabilitation are correlated with use of outcome measures, specifically: comprehensive assessment of medical problems, body structure/function and participation; early assessment and planning for discharge needs HOW TO USE OUTCOME MEASURES TO GUIDE INTERVENTIONS: EXAMPLE: The stated problem from both of these 67 yo female patients is: I am having trouble getting around and doing my household duties. I also am having freezing episodes Patient A: lives alone MDS-UPDRS part II, patient questionnaire: indicates moderate difficulty with dressing, hygiene, turning in bed and getting out of bed (expresses minimal difficulty with function outside the home) PDQ-8 often feels depressed and has dressing problems, but no issues with feeling lonely or unable to socialize Patient B: lives with husband MDS-UPDRS part II, patient questionnaire: indicates moderate difficulty with hobbies, walking and balance and freezing and rates dressing and hygiene as less difficult PDQ-8 often feels depressed and difficulty getting around in public and embarrassed in public

3 CASE SUMMARY Findings provide further insight into which functional impairments are having the biggest impact on mood and quality of life. The focus of therapy would be quite different for these individuals While they may both have same impairments Patient A has revealed that she wishes to focus on ADLs in her home while Patient B is focused on mobility outside the home. Freezing can be recalcitrant to treatment, yet treatment may improve function without changing the underlying issue of freezing in a measurable way. The PDQ-8 and UPDRS showed meaningful progress and goal achievement for these 2individuals. USE OF OUTCOME MEASURES: CASE EXAMPLES Multiple case examples will be presented to demonstrate how outcome measures can be used to improve care across the stages of disease in Parkinson s Disease Part 1 H&Y I (Terry Ellis and Jeffrey Hoder) Part 2 H&Y II and III (Cathy Harro and Erin Hussey) Part 3 H&Y IV (Rosemary Gallagher and Suzanne Oneal) 14 EXAMINATION OF PATIENTS WITH PARKINSON DISEASE IN THE EARLY STAGES TERRY ELLIS, PT, PHD, NCS BOSTON UNIVERSITY JEFF HODER, PT, DPT, NCS VIRGINIA COMMONWEALTH UNIVERSITY APTA COMBINED SECTIONS MEETING FEBRUARY 4, 2014 LAS VEGAS, NEVADA TREATMENT GOALS Slow Progression of Disability Optimize independence and participation in home, work and leisure activities Optimize independence and safety in performing function tasks (gait, balance, sit to stand, bed mobility, ADL s) Preserve or improve physical capacity (cardiovascular endurance, strength and flexibility) Prevent falls reduce fall risk CURRENT MANAGEMENT MODEL FOR PARKINSON DISEASE PROACTIVE MODEL OF CARE IN PARKINSON DISEASE Figure 2. Proposed proactive physical management model of Parkinson's disease. A Proactive Physical Management Model of Parkinson's Disease. Turnbull, George; PT, PhD; Millar, Janet; PT, BSc Topics in Geriatric Rehabilitation. The Older Driver, Part 2. 22(2): , April/June A Proactive Physical Management Model of Parkinson's Disease. Turnbull, George; PT, PhD; Millar, Janet; PT, BSc Topics in Geriatric Rehabilitation. The Older Driver, Part 2. 22(2): , April/June

4 CASE STUDY Categorizing Outcome Measures what are we trying to measure? Health Condition Parkinson s Disease International Classification of Functioning, Disability and Health (ICF) FD is a 54 year old R handed male Diagnosed with PD 6 months ago Body Functions & Structures (Directly Related to PD) Tremor, Bradykinesia, Rigidity Body Functions & Structures (Indirectly Related to PD) Flexibility, Endurance GOALS: Regular Exercise Program Best Exercises for PD Slow disease progression Reduce stiffness Initial symptoms: decreased arm swing micrographia Meds: Sinemet ½ tab 3x/day; Azilect 1 mg Social: lives with wife and 4 teenage children; Working full-time as plumber & property manager Environmental Factors Home and community settings Activities Walking, ADL s, Balance Participation Ability to work, to interact socially, to perform self-care Personal Factors Resources, personal attitudes, emotions & feelings OUTCOME MEASURES Outcome Measure October 2011 Normative Values Participation: PDQ (0-100) N/A Activity: 9 Hole Peg Test R= 30; L= 22 R=19; L=20 Six Minute Walk Test 528 meters meters 10 Meter walk (comfortable) 1.5 m/s 1.4 m/s 10 Meter walk (fast) 2.0 m/s 2.1 m/s Sit to Stand 5x (1.5) Freezing of Gait Questionnaire 0/24 low = better FGA 28/30 30 max score Mini BESTest 26/28 28 max score UPDRS II (ADL s) 18 N/A Body Structure & Function: UPDRS I (non-motor) III (motor) 2 34 N/A N/A MoCA (Montreal Cognitive Assess) 27 > 26 cut-off MCI) KEY ELEMENTS OF PHYSICAL THERAPY INTERVENTION BUILD CORE SELF-MANAGEMENT SKILLS Promotion of physical activity and lifelong adherence to an exercise program Prevention / Management of Secondary Sequelae Fall Prevention / Risk Reduction Strategy Training Lorig KR et al. Ann Behav Med 2003;26(1):1-7 Problem Solving Taking Action Decision- Making Self- Management Effective Resource Utilization Patient / Health-Care Provider Partnership 4

5 Outcome Measure October 2011 April 2012 Participation: PDQ Activity: 9 Hole Peg Test R= 30; L= 22 R=27; L=22 Six Minute Walk Test 528 meters 570 meters 10 Meter walk (comfortable) 1.5 m/s 1.5 m/s 10 Meter walk (fast) 2.0 m/s 2.2 m/s Sit to Stand 5x 9.5 secs 7.6 secs Freezing of Gait Questionnaire 0/24 0/24 FGA 28/30 28/30 Mini BESTest 26/28 26/28 UPDRS II (ADL s) Body Structure & Function: UPDRS I (non-motor) III (motor) MoCA (Montreal Cognitive Assess) CASE: DC DC: MEDICAL HISTORY DC is a 65 year old right handed female Diagnosed with PD in October of 2012 Initial symptoms: right-sided tremor and stiffness, as well as dragging her right foot when she walks Meds: Sinemet 25/100 q 4 hrs; Amantadine 100 mg o.d.; Levothyroxine o.d. PMH: PD as above, thyroid disease DC: HISTORY She reports feeling unbalanced, but denies any falls to the ground. She acknowledges a fear of being imbalanced. She states that her walking is limited due to increased effort. She reports feelings of weakness when walking and when climbing stairs. DC: SOCIAL DC: ADL INDEPENDENCE Social History: She currently works 30 hours per week as a financial planner. She was born in China, raised in Taiwan and moved to the US in College educated. She lives with her husband in a 2-story, private home with her husband. There are 4 steps to enter through her garage. She has one daughter, one son and one grandchild. Her children live locally. *No physical barriers noted in living environment which would impede safe performance of activities of daily living. Independent with all activities of daily living. Requires increased time to accomplish tasks when medication is low in her system. Her right arm and leg get very stiff. She is independent with self care, cooks with her husband, generally independent with household chores but recently has hired a housekeeper who comes every 3 weeks, manages her finances, drives without a problem. 5

6 HEALTH STATUS Health Status/Activity Level: Smoke: Denies Exercise: Exercises regularly at the YMCA: body sculpting classes 2x/week; Tai Chi class 3x/week; Yoga classes 2x/week. She reports stretching every morning. DC: GOALS Patient goals: I want to enjoy walking again. I want to strengthen my joints. Vital Signs VIDEO OF GAIT Position: Sitting in chair Standing (immediate) Standing (after 2 minutes) no symptoms reported Sitting in chair following gait testing BP=103/55, HR=78 BP=99/56, HR=83 BP=106/60, HR=84 BP=123/63, HR=85 Highly recommended measures: Body Structure and Function MDS-UPDRS revision* - part 3 MDS-UPDRS part 1 Activity 6minutewalk 10 meter walk Mini BESTest MDS-UPDRS part 2 Participation PDQ-8 or PDQ-39 Montreal Cognitive Assessment Functional Gait Assessment Sit to stand 5 times 9 hole peg test All measures in the highly recommended category are also recommended for use in research and students learn to administer. * recommend students exposed Recommended Measures for Specific Constructs Freezing of Gait Freezing of Gait questionnaire Fatigue Parkinson's Fatigue Scale Fear of falling ABC scale Dual Task Timed Up and Go cognitive 35 Outcome Measure October 2013 Normative Values Participation: PDQ (0-100) N/A Activity: 9 Hole Peg Test Not Tested R=19; L=20 Six Minute Walk Test 345 meters meters 10 meter walk (comf) 0.96 m/s 1.4 m/s Sit to Stand 5x 9.6 seconds < 11.4 s (Bohannon, 2006) FGA 23/30 30 max score Mini BESTest 24/28 28 max score Body Structure & Function: H & Y 2 N/A MoCA (Montreal Cognitive Assess) 29/30 < 26 cut-off MCI 6

7 GENERAL EXERCISE RECOMMENDATIONS COMFORTABLE GAIT: JANUARY 2014 Flexibility training based upon Axial Mobility exercise program: (DAILY) (Chandler and Schenkman, 2004) Weight training: (2x /week) Continue with your exercise classes at the YMCA. Consider adding more aggressive resistance training of circuit training to your routine (discuss with a trainer). (Corcos et al, 2013) Walking training: POWER WALKING! Metronome training at her established cadence with focus on improving stride length. (110 beats per minute) GAIT TRAINING: JANUARY 2014 Outcome Measure October 2013 January 2014 Participation: PDQ (0-100) 4.5 Activity: 9 Hole Peg Test NT NT Six Minute Walk Test 345 meters 475 meters 10 meter walk (comf) 0.96 m/s (1.4 m/s) 1.15 m/s (1.26 m/s with metronome) Sit to Stand 5x 9.6 seconds 8.7 seconds FGA 20/30 23/30 Mini BESTest 24/28 25/28 Body Structure & Function: H & Y 2 MoCA (Montreal Cognitive Assess) 29/30 (< 26 cut-off MCI) NT QUESTIONS PARKINSON S EDGE Outcome Measures Guide Decisions Wellness Programs Individualized Programs Cathy Harro, PT, MS, NCS Grand Valley State University Erin Hussey, DPT, MS, NCS University of Wisconsin La Crosse 7

8 ASSESSMENT SUPPORTS OPTIMAL MANAGEMENT FOR FUNCTION WELLNESS CLASS MODELS FOR PD Outcome Measures Mixed group Clients represent varied neurologic disorders Program targets general fitness, wellness & prevention Wellness Program Individualized Therapy PD Spectrum Program targets only PD clients across all HY stages Specialized classes to address PD specific deficits Focused Program targets only PD clients at selected HY stage Specialized classes OUTCOME MEASURES SUPPORT BEST FIT OUTCOME MEASURES (OM) FOR WELLNESS PROGRAMS Supports providing best fit of participant and program & guides needs of program Hoehn & Yahr II-III Noticeable PD symptoms/signs Increased fall risk Functionally independent Likely to participate and to benefit from participation Clinical Example: Use of intake assessment to match client to appropriate wellness programs Example: H&Y 1 higher level generalized fitness Example: (HY stages II, III, IV) program designed for impairments specific to PD OM used to: Assess program needs Assess program effectiveness Help educate and motivate clients Determine need for referral to individualized program/therapy RECOMMENDED MEASURES TO CONSIDER FOR WELLNESS PROGRAMS VIDEO SEGMENT 1- EXERCISE CLASS COMPONENTS BASED ON FGA FINDINGS Activity 10 meter walk test (gait speed) 6 minute walk test (gait capacity, fitness) Functional Gait Assessment (balance & mobility) Mini-BEST test (balance, fall risk) Sit to stand 5 times (functional strength) Timed Up and Go Cognitive (dual task) Participation PDQ-8 (quality of life) 8

9 VIDEO SEGMENT 2- EXERCISE CLASS COMPONENTS BASED ON FGA FINDINGS Insert video: CSM-CH-FGA Test-Treat2 VIDEO SEGMENT 3- EXERCISE CLASS COMPONENTS BASED ON FGA FINDINGS Insert video: CSM-CH-FGA Test-Treat OUTCOME MEASURES DEMONSTRATE PROGRAM EFFECTIVENESS PD clients in HY stages II & III {group data} Pre-Post summary of gains with 12-week program Sit-Stand x5* TUG-Cog Gait Speed 6 MWT* % Improved % Exceed MDC STS-5, MDC 4.2 sec Gait speed, 0.18 m/sec 6 mwt, MDC 82 meters * Significant at p < 0.05 OUTCOME MEASURES PARTICIPANT EDUCATION REGARDING VALUE OF EXERCISE *In Program Gains vs. Off Program loss PERSONALIZED REPORT Dear Charlie, Thank you for participating in the Wellness Program. You made some gains, great job. Here is a brief summary of improvements: TEST CHANGE Timed Up and Go (Mobility) (Get up from chair, walk 10 feet, turn around and return to chair) Sit to Stand 5 repetitions (Strength) Improved by 4 seconds in the dual task condition (walking while doing a math challenge) Improved by 8 seconds 6 Minute Walk test (Endurance) Improved by 64.5 meters OUTCOME MEASURES FACILITATE ENGAGEMENT & CLIENT MOTIVATION I was so happy with my report card that I brought my report to my neurologist and to my [clinical] PT appointments My medical doctor told me that they have never seen someone with Parkinson s improve like I have I am so pleased with this program; thank you for the summary and encouragement 9

10 OUTCOME MEASURES PROVIDE LONGITUDINAL SUMMARY OF CLIENT STATUS Example : o Gait speed for one participant 2012 = 1.0 m/sec 2013 = 0.60 m/sec In 2013, this decline coincided with reports of freezing while walking and a fear of falling Recommended: revisit with neurologist and an individualized physical therapy episode of care VALUE OF OM FOR WELLNESS SUMMARY Guide selection of appropriate program components for target group Assess program effectiveness to trigger change Demonstrate program effectiveness to external groups and to individual participants Identify those in need for PT/neurologist referral USE OF OUTCOME MEASURES IS BENEFICIAL TO SERVICE-BASED STUDENT LEARNING OUTCOME MEASURES FOR INDIVIDUALIZED PHYSICAL THERAPY I really see how important it is to use outcome measures correctly, otherwise it loses all value We thought she was doing better, but it has been great to see how much the measurements help show the details of improvement Our client is so high level we were not sure what to do initially, but the dual task and functional challenges and measurements helped us know how to develop his program Hoehn & Yahr II-III OM value Gradual changes in PD symptoms affecting function May notice decline in balance skills, confidence & in fall risk Likely to express concerns to MD and be referred to physical therapy Guide PT interventions Assess treatment effectiveness Help educate and motivate client Demonstrate effectiveness for external review & reimbursement PHYSICAL THERAPY EVALUATION IN PD SPECIAL CONSTRUCTS IN PD EVALUATION Selection of Valid & Sensitive Measures to Assess Key Areas ADL Skills & Activity Mobility & Gait Skills Functional Strength Balance Fall Risk Freezing of Gait questionnaire Freezing of Gait Balance confidence PD Evaluation Activities Specific Balance Confidence Scale Dual Task Ability TUG-Cognitive Individualized Physical Therapy Plan of Care Parkinson s Fatigue Scale Fatigue Cognitive Function Montreal Cognitive Assessment 10

11 CASE #1 Measure Baseline Outcome Sit to Stand x sec 9.7 sec Mini BEST test Includes TUG and TUG-Cog Total: 17/28 16 sec 24.8 sec (55% slower) Total: 22/28 12 sec 14.2 sec (18% slower) Insert video: CSM-EH_FTS-3clips Gait Speed 0.78 m/sec 0.95 m/sec ABC 72% 70% REACTIVE BALANCE WITHIN THE MINI-BEST TEST CASE #2: EXPERIENCING INCREASED FALLS Insert video: CSM-EH-Reactive Balance Added Measures ABC FOG-Q Intervention Task-specific mobility training Environmental modifications Outcomes Reduced fall frequency 4 per week 1 fall in 8 wks ABC up by 24% FOG-Q showed less freezing Sample from the Freezing of Gait Questionnaire. Giladi et al, 2000 CASE #3: MIXING UP APPOINTMENTS & HOME PROGRAM DETAILS Insert video: CSM-EH-Freeze Short Added: MoCA (Score of 22/30) Adjusted for health literacy & memory Consultation with Neurologist No more missed appointments; Improved consistency with prescribed home program 11

12 FOR MIDDLE STAGES OF PD OUTCOME MEASURES To guide clinical decisions for interventions To demonstrate treatment effectiveness Support patient motivation and confidence OUTCOME MEASURES FOR PATIENTS WITH PARKINSON S DISEASE STAGE IV H&Y Wellness Program Individualized Therapy Rosemary Gallagher, PT, DPT, GCS New York Institute of Technology Suzanne O Neal, PT, DPT, NCS Scottsdale Healthcare HOEHN AND YAHR CLASSIFICATION TREATMENT GOALS STAGE IV Severe symptoms Tremor may be less than earlier stages Stage IV Limited Walking Ambulation Transfers ADL s Safety Functional Adaptation Compensatory Strategies Caregiver Education Wellness Program Periodic check up s with PT Community Based Support No longer able to live alone Rigidity and Bradykinesia Hoehn and Yahr, 1967 CHOOSING APPROPRIATE OUTCOME MEASURES FOR STAGE IV Measures are chosen based on therapeutic goals and strong psychometric properties for Stage IV Establish baseline Determine POC Monitor progress and effectiveness of POC CASE STUDY: MEDICAL HISTORY BG is a 61 year old male Diagnosed with PD in 2006 PMH: Neg for HTN, high cholesterol, and diabetes Meds for PD: Sinemet, Amantadine s/p bilateral GPi DBS 11/2013 due to increased symptoms severely affecting ADLs and overall functioning 12

13 CASE STUDY: SOCIAL Married, lives in 1 story home HHA 5 days (M-F) 8 hours Wife recently returned to work after medical leave (8/2013 husband fell on her- fx shoulder) College grad, worked in retail sales Retired 7/2011 due to PD causing difficulty performing job duties. CASE STUDY: MOBILITY Ambulates with rollator walker States he is independent with bed mobs, dressing, shaving and showering, some difficulty with transfers Reports progressive increased difficulty with chores around house FOG when OFF meds (turning and initiation of gait) Exercises 30 min/day on theracycle BASED ON THE PATIENT S GOALS AND DEFICITS THE FOLLOWING MEASURES WERE CHOSEN: Impairment of Body Function (UE Coordination): 9 Hole Peg Test Activity Limitation (Transfers): 5x Sit to Stand Participation Restriction (Functional Mobility and Dual Tasking): TUG and TUG Cog Participation Restriction (Gait Speed): 10 Meter Walk Test USE OF OUTCOME MEASURES IN STAGE IV: POST DBS Assist rehab team/md to determine optimal stimulation parameters for therapeutic effect Assess for new or increased concerns regarding balance/fall risk that can occur with DBS OFF DBS: Right=28.8s Left=43.96s 9 HOLE PEG TEST 9 HOLE PEG TEST Excellent Test-Retest Reliability ICC = 0.88 (dominant) & 0.91 (non-dominant) Minimal Detectable Change (MDC) 2.6 seconds (dominant) 1.3 seconds (non-dominant) Earhart et al,

14 WHY USE THE 9 HOLE PEG TEST IN A PT SETTING? 5X SIT TO STAND STANDARDIZED METHOD Motor symptoms of PD affect the UE UE motor symptoms have been associated with difficulty/limitations in ADL s and can adversely affect QOL Some patients may not have OT coverage or orders for OT. PTs cannot lose sight of the whole patient! OFF ON 5X SIT TO STAND MODIFIED METHOD 5X SIT TO STAND Excellent Test-Retest Reliability ICC = 0.91 Cut Off Score of 16s to discriminate fallers from non-fallers 5xSTS (off)=30.18s 5xSTS (on)=13.59s Paul et al, 2012 Duncan et al, 2011 TIMED UP AND GO WITHOUT AND WITH COGNITIVE TASK 10 METER WALK TEST COMFORTABLE SPEED TUG=49.3 sec TUG Cog= 2 min 1.3 sec Gait speed = 0.36 meters/second (off) 0.57 m/s (on) 14

15 10 METER WALK TEST Excellent Test-Retest Reliability ICC = 0.96 (comfortable speed) & 0.97 (fast speed) Minimal Detectable Change (MDC) 0.18 m/s (comfortable speed) 0.25 m/s (fast speed) RECOMMENDATIONS FOR THIS PATIENT: Begin/resume physical therapy Join a wellness program specific to people with PD Schedule periodic check-ups with PT (i.e. quarterly, biannually, etc..) Refer to support group and/or other supervised community based programs specific for people with PD Caregiver/spouse education for home program if applicable Steffen & Seney, 2008 PATIENT A PATIENT B Patient A: 82yo male Initial evaluation: 5xSTS: 13 seconds 9HPT: Dominant = 42.5 seconds, non-dominant: =45.0 seconds Intervention: 2xweek /8 weeks Post: 5xSTS: 12 seconds 9HPT: Dominant = 41.0 seconds, non-dominant = 43.8 seconds 7 Month follow up: 5xSTS: 16 seconds (at cut-off score for fallers) 9HPT: Dominant = 48.6 seconds, non-dominant: =50.3 seconds Intervention: 2x week/4 weeks Post: 5xSTS: 13 seconds 9HPT: Dominant = 43.6 seconds, non-dominant = 47.6 seconds Patient B: 89 y.o. male Initial eval: 5x Sit to Stand: 62 seconds PT 2x/week for 5 weeks 5x Sit to Stand at D/C: 33 seconds Returned for check up 7 months later = unable to complete full 5xSTS test (after 2 transfers, failed on third attempt) SUMMARY: The use of outcome measures in Stage IV PD should include those performed during the earlier stages when able to ensure uniformity of measurement as the disease progresses. This allows the clinician to track a patient s progress and change the goals and focus as needed. Deb Kegelmeyer CONCLUDING COMMENTS 90 15

16 CONSIDERATIONS IN THE USE OF OUTCOME MEASURES WHEN DOING REPEATED ASSESSMENTS Remember that some measures are sensitive to learning (MOCA) and so should not be repeated too often It is key to repeat measures at intermediary time points to determine if the treatment is progressing towards the activity and participation goals If the progress isn t adequate the findings can help guide changes in treatment MORE CONSIDERATIONS: MDC AND MCID Studies in PD are small or there are none Clinicians should be conservative and cautious in changing care decisions based on these Clinical common sense should also be applied. 91 KEY POINTS The use of a Core Set of Outcome Measures allows us to show change: Over time Within an episode of care Over the course of the disease gives therapists a common language to be able to compare data across clinics across the U.S. enable creation of a database that would allow us to ask important questions about interventions and their effectiveness allows the client s PT assessments to follow them from one setting to another and across the continuum of care 93 AREAS FOR FUTURE RESEARCH Determination of measures that are responsive over the full continuum of the disease. Investigation of response to therapy across multiple clinics using a database composed of a core set of measures Large studies are needed to more fully examine psychometrics in PD such as MCD and MCID FUTURE RESEARCH (CONT.) IMPORTANT LINKS The future of measurement is likely to include more instrumental means of measuring functional change These clinical measures are great for giving us a "snapshot" into the functional status of patients with PD - at one moment in time. However, persons with PD fluctuate We also know that what we observe in the clinic may not be what the patient is experiencing at home / community; so more continuous measures of function in the home/community setting may become more common in the future in clinical practice. Rehab Measures Web site: PDEDGE

17 THANK YOU! Jane Sullivan Patty Sheets The Neurology Section Rehab Measures The many students and co-workers who provided input and support throughout this process. 17

18 Standardized Measures targeting those values reported for Parkinson Disease Measure Reported cut-off scores - falls risk Reported MDC Activities specific Balance Confidence PD: 69% Mak & Pang 2009 PD: 11% PD: 13% Functional Gait PD: < 18/30 Yang 2014 Not established for PD Assessment Elderly: <22/30 Wrisley 2010 Stroke: 4.2 points 5x Sit-to-Stand PD: 16 sec Duncan, sec Schaubert 2005 Del Bello-Haas et al, 2011 Steffen & Seney 2008 Lin et al 2010 Notes Gait speed 10 meter walk test Not established PD: Usual pace 0.18 m/s PD: Fast pace 0.25 m/s Steffen & Seney 2008 Mini-BEST PD:<19/28 Mak & Auyeung, 2013 Not established for PD Varied Neurol Dx: MDC 3.5; MCID=4pts Godi, 2012 Timed Up & Go PD: 11 sec Nocera et al, 2013 PD: 11 sec Steffen & Seney, 2008 Early PD: 7.95 sec Dibble et al, PD: 5 sec Dal Bello-Haas et al, 2011 TUG Cognitive 2006 Elderly: <15 sec Shumway- Cook et al, minute walk test Not established Correlations to health status are published Not established PD: 82 meters Steffen & Seney, 2008 MB total score is 28 Horak, test instructions Included in Mini-BEST test with rating adjusted if >10% decline from TUG to TUG-Cog 9 Hole Peg Test Not applicable to falls risk PD: 2.6 sec - dominant hand; 1.3 sec non-dominant hand Earhart 2011 Montreal Cognitive Assessment (MoCA) Not applicable to falls risk <26/30 Mild cognitive impairment Hoops et al <22/30 Dementia Robbens et al, 2010, Dalyrimple-Alford et al, Draft created Jan 2014 These values represent current available evidence with a focus on studies providing specifics for Parkinson Disease (PD). Note that some of these cut points and responsiveness indicators have been established based on a small sample size of those with PD. The stability and strength of these values is expected to improve and change with additional research and require updating. In addition, any individual test psychometric must be used in context of the comprehensive PT exam and reassessment and does not replace clinical judgment.