Evaluation is designed to obtain a general impression of the patient’s clinical status, her/his social circumstances and a detailed description of her/his physical problems.
The evaluation begins with the complete examination of the manifestations of the present symptoms. The degree of commitment and the effect on the functional activities are recorded.
General Information
It is important to consider the complete medical history in order to determine whether there are other factors concomitant with Parkinson Disease that affect the patient’s general health and mobility, e.g.: arthritis or hemiplegia.
The history of the disease must be considered, as well as its duration, physical signs and symptoms. Among them tremor, rigidity, pain and all the abovementioned are included.
The patient’s medications and their dosages must be taken into consideration, given that they may cause alterations in the performance of her/his activities. A complete social history is needed in order to ascertain if the patient is working or retired, what kind of work s/he does, which are her/his pastimes and how s/he spends her/his day. It is also relevant to determine whether the patient lives alone, any service s/he may receive, such as home delivered food.
Physioterapeutic Evaluation
The patient’s posture, balance and functional performance are taken into account. The functional performance of many patients is modified during the day, so it is important to register the time in which the evaluation takes place and the time since the intake of the last medication dose.
Posture
Given that posture is invariably affected, it must be evaluated using a scale from 1 to 4. Gradation in graphics is the easiest method that can be employed (Table 1). Similar gradations may be used in a sitting or lying position in case it is relevant for the individual.
Balance
In order to test the balance reaction, the patient is requested to:
1.- Be seated with no support for a minute.
2.- Remain standing with no assistance for five seconds.
3.- Remain standing on one foot and then on the other with no assistance for five seconds.
The aim of this is to observe tolerance and features of the patient's balance.
Functional Evaluation
Common difficulties such as turning in bed, to sit from a lying position and to stand up from a sitting position must all be timed and graduated. The gradation scaled used is the following:
1.- Normal.
2.- Can perform a task with some difficulty but with no assistance.
3.- Can perform a task with assistance, such as pulling from the side of the bed.
4.- Unable to perform a task.
When appropriate, the same gradation and times evaluation can be used to record the performance of other functional difficulties.
Walking must be evaluated allowing the patient to walk a fixed distance, recording the number of steps and the time used in covering said distance. The quality of heel tapping must be observed. It can be divided into the following three categories:
1.- heel-toes,
2.- flat foot and
3.- toes-heel.
Film recording of walking patterns is also part of the evaluation in order to measure improvements or deteriorations.
In addition, the patient’s ambulatory posture must be observed and whether s/he has any difficulty in initiating the movement. Any assistance used for walking must be noticed.
Finger skills can be evaluated allowing a maximum of three minutes for the patient to do up three buttons of a shirt. The number of buttons and the time used will be noted.
Additional Evaluations
These evaluations aim at taking account of the following:
- Articular passive movement arc: the presence of contractures can be detected.
- Articular active movement arc: the movement characteristics can be determined.
- Tremor and rigidity presence and characteristics. Tremor is observed and the maximum distance of the tremor course is calculated combined in both directions. Neck rigidity is studied by means of the passive flexion, extension and rotation.
- Pain or other discomfort is present.
- Functional activities: personal cares, everyday activities, communication, coordination, strength, reach, pressure.
- Work position and potential.
- Non vocational interests and abilities.
- Emotional status.
- Self-attention.
- Situation at home, lifestyle, social interests and responsibilities.
- Speech: evaluated while having normal conversations.
- Verbal learning test: used to check immediate memory magnitude, learning and late evocation of the verbal material. It consists of a list of fifteen words read to the patient who must repeat at intervals during the evolution.
- Verbal comprehension test: used to check the patient’s comprehension of verbal instructions. It consists of providing groups of instructions of increasing complexity for the patient to follow.
- Seborrhea: asking about the frequency with which the patient washes her/his hair can reveal the presence of too much fat.
- Facies: observations are done during conversation and at rest.
Standarized Evaluations
- Master copy of Evaluation Areas, Components and Occupational execution contexts.
- Physical Red Cross Scale.
- Mental Red Cross Scale.
- Balance and Walking Tinetti’s Scale.
- Geriatric Depression Scale summarized.
At the end of the therapeutic evaluation the severity of the patient’s disease should be oldclassified using Haehn and Yahr Scale and treatment objectives should be enumerated.
Treatment Objectives
Once the evaluation is finished, it is the time to consider the objectives that should result realistic in reference to the patient’s situation, the stage in which the disease is and its individual characteristics, not neglecting each person’s interests.
Given that this is a disabling disease, the general objectives are:
- To improve and keep independence in occupational areas during the longest possible time.
- To improve the quality of life and personal well-being.
- To keep residual abilities.
- To improve the feeling of competition and self-esteem.
- To improve communication and cognitive abilities.
- To provide family advice.
In order to achieve these objectives it is necessary to set up specific objectives such as the following:
- To improve coordination and motor abilities.
- To increase motivation and improve the state of mind.
- To correct the generalized attitude of flexion.
- To correct block movements.
- To lessen rigidity.
- To teach relaxation techniques.
- To foster functional use of the relearned abilities.
- To prevent deformities, articular retractions, posture disorders, etc.
- To keep or improve articular trajectories.
- To supply the adequate technical assistance and environment modifications.
Treatment
The treatment for Parkinson Disease may be pharmacological, physiotherapeutic, Occupational Therapeutic, language therapeutic and/or surgical. The objective of the treatment is to reduce the speed of progression of the disease, to control the symptoms and secondary effects derived from the medicines used to counteract it.
Medicines:
Amantadine may help patients with minor symptoms but without disability.
Anticholinergics: they are useful for alleviating tremor and rigidity, initiating its administrations with small doses that will be increased gradually until results are obtained or until secondary effects are greater than the benefits.
Levodopa: this medicine improves the whole symptomatology of Parkinsonism, including bradycinesia. But it does not stop the evolution of the pain. The way the organism behaves is with the transformation of this medicine into dopamine at intake.
Bromocriptine: this medicine works directly at the dopamine receptors and produces less secondary effects than levodopa. It is usually reserved for those patients that have become levodopa resistant.
Surgical Treatment
Thalamotomy is recommended for relatively young patients with tremor and rigidity predominantly unilateral not responding to the pharmacological treatment and with no evidence of diffuse vascular disease.
Given that Parkinson Disease is a progressive illness, any treatment must be concerned with helping the patient achieve her/his optimal physical potential, thus allowing her/his quality of life to improve at that moment. Even when the difficulties and objectives will vary permanently in the progression of the disease, it is essential to prolong the patient’s functional independence.
The history of the disease must be considered, as well as its duration, physical signs and symptoms. Among them tremor, rigidity, pain and all the abovementioned are included.
These evaluations aim at taking account of the following:
