Predicting Fall Risk in Patients with Parkinson’s Disease CPS I Presentation By: Devin Henry

Purpose To investigate the Timed Up & Go as an effective tool to predict falls in patients with Parkinson’s disease

Demographics Gender: Male DOB: 3/10/1938 Race: Caucasian Diagnosis: Parkinson’s Disease (PD) Symptoms poorly controlled

Parkinson’s Disease Progressive neurodegenerative disease that affects movement Primary motor signs include tremor, bradykinesia, rigidity, and postural instability

Past Medical History Repeated falls Left humeral fracture Arthritis Benign prostatic hyperplasia Vitamin D deficiency Hyperlipidemia and hypertension (taking medication)

PT Examination Presented to home health due to recent falls Resides in an assisted living facility and has assistance for meals, medications, and ADLs Home environment is very cluttered which limits safe mobility Alert & oriented x 4 Available DME includes tub chair, cane, wheelchair, bed side commode, grab bars, and rollator

PT Examination Demonstrates generalized muscle weakness and limited range of motion bilaterally Performs sit to stand with contact guard assist Ambulates 75 ft on a level surface with rollator—requires ambulator at all times TUG: 46 seconds with rollator

ICF Model Health Condition Parkinson’s Disease Impairments Decreased strength, decreased balance, decreased ROM, impaired gait, hypophonic speech Activity Limitations Difficulty moving and walking, trouble with communication Participation Restrictions Unable to ambulate to meals without assistance, unable to groom self

Prognosis Poor Due to The progression of Parkinson’s Disease Currently taking 5 or more medications History of falls

Plan of Care Gait training, balance training, transfer training and patient education to improve functional mobility and increase safety in current environment Will see patient for 4 weeks Start with 3 times per week Progress to 2 times per week

PT Goals Sit to stand: Gait: STG: In two weeks, the patient will be able to transfer sit to stand with standby assist LTG: In four weeks, the patient will be able to transfer sit to stand with modified independence. Gait: STG: In two weeks, the patient will be able to ambulate 150 ft on a level surface with a rollator with standby assist. LTG: In four weeks, the patient will be able to ambulate 300 ft on a level surface with a rollator with modified independence.

Interventions Gait training Transfer training Balance training Visual cues with cones and agility ladder Metronome Transfer training Balance training Patient education Safety with ambulation Techniques to decrease festinating gait

Outcomes Patient performs sit to stand with modified independence Patient progressing toward ambulation goal, but still required verbal and auditory cues Object negotiation improved as demonstrated by fewer freezing of gait events

Is the Timed Up & Go an accurate clinical predictor of future falls in my 78 year-old patient with Parkinson’s disease?

Article 1 Published in Movement Disorders in January 2016 2015 Journal Impact Factor: 6.01 (14th in Clinical Neurology category)

Overview Literature review of 1391 articles Evaluated various studies that measure balance, posture, and gait in patients with PD The purpose was to begin assessing which screening tools or which outcomes are preferred in monitoring patients with PD Classified each tool as “recommended,” “suggested,” or “listed” Included studies that investigated rating scales, questionnaires, and clinical tests Performed searches in PubMed, EMBASE, Web of Science, Cochrane, and PyscInfo Articles chosen by a group of professionals—3 neurologists, 2 physiotherapists, 1 movement scientists, and 1 epidemiologist) Evaluated strengths and weaknesses of each and decided

Timed Up & Go Adequate test-retest and inter-rater reliability (ICC ranging from 0.80-0.99) Score > 7.95 seconds may indicate a high risk for falling Satisfactory construct validity in PD Walking speed, stride length, and turning ability Applicable to patient with PD Demonstrates ability to differentiate between stages of disease Easy to administer and useful for measuring outcomes

Results “Recommended” “Suggested” UPDRS-derived Postural Instability and Gait Difficulty score Berg Balance Scale, Mini-BESTest, and Dynamic Gait Index Freezing of Gait Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Survey of Activities, and Fear of Falling in the Elderly—modified 6-minute walk test, 10-m walk test, Timed Up-and-Go, and Functional Reach Tinetti Balance Scale Rating Scale for Gait Evaluation No single scale was suitable for all clinical purposes to asses gait, balance, and posture due to the heterogeneity in the pathophysiology of PD.

Limitations Rating scales that required extra tools for administration were excluded Included a large number of studies Literature search was limited to articles in English Lack of demographics of patients included

Article II Published in Archives of Physical Medicine and Rehabilitation July 2013 2015 Journal Impact Factor: 3.045 (4th in Rehabilitation category)

Overview Cross-sectional cohort study The purpose was to investigate the Timed Up & Go as a tool to accurately identify patients with PD at risk for a fall

Participants Data obtained from 16 National Parkinson Foundation Centers of Excellence Included all patients registered with the National Parkinson Foundation’s Quality Improvement Initiative Registry (NPF-QII) Excluded cases with lack of crucial information Age, diagnosis, disease duration, etc. Resulted in 2101 cases total All evaluations were done in the “on” medication state

Methods Primary outcome measure was falls Collected via self-reported history Chief independent variable was the TUG test Binary logistic regression Collected covariates: Disease duration and severity (Hoehn and Yahr [H&Y] stages) Quality of life using PDQ-39 Executive function abilities Presence and severity of arthritis Conducted a second analysis with the TUG x H&Y stage Performed a receiver operating characteristic (ROC) curve to identify the optimal cut score for the TUG collected via a self-reported history over the past 3 months and dichotomized into two groups Binary Logistic regression:  estimates the probability that a characteristic is present

Results The first model focused on the prediction of falls from the TUG test, adjusting for all study covariates 74% of participants accurately classified Each 1-second increase associated with a 2.3% increase in falls The second model focused on whether the effect of the TUG test was applicable across H&Y stages 75% of participants accurately classified Each 1-second increase associated with a 5.4% increase in falls

Results Conclusion: The TUG demonstrates a good association with occurrence of falls, even after controlling for covariates with a proposed cut off score of 11.5 sec Sensitivity: .66 Specificity: .62

Limitations Use of self-reported fall history Evaluation during the “on” medication state Patients were receiving therapy from National Parkinson Foundation Centers of Excellence Cross-sectional cohort study

So is the TUG the best tool for my patient to predict fall risk? Based on the previous studies presented, the TUG is a valuable tool in predicting fall risk in my patient Severity of disease does not affect its value However, it cannot be the only evaluative tool considered when determining fall risk Important to observe other aspects of gait as it relates to the patient

References “Measurement instruments to assess posture, gait, and balance in Parkinson’s Disease: critique and recommendations.” Bloem, B. et al. Movement Disorders. 2016 January; 31 (9): 1342-1355. “Using the timed up & go test in a clinical setting to predict falling in Parkinson’s disease.” Nocera, J. et al. Arch Phys Med Rehabi. 2013 July; 94(7): 1300-1305. Parkinson’s image: http://www.pdaids.com/swallowing-problems- can-be-fatal-for-pd-patients-part-ii/ Future Image: http://phoenixrising.me/mecfs-basics/chronic- fatigue-syndrome-mecfs-prognosis-and-treatment-success-rate-by- cort-johnson-2

Questions?