In de volgende paragrafen wordt – in alfabetische volgorde – kort aangehaald welke aandachtspunten er zijn bij de ziekte van Parkinson en, indien van toepassing, wat de toegevoegde waarde van het instrument is ten opzichte van andere instrumenten.

 

Zes Minuten Wandeltest (6MINWT)

Aandachtsgebieden: fysieke capaciteit en lopen

De 6MINWT is geschikt om op een objectieve manier de submaximale functionele inspannings-capaciteit te beoordelen en te evalueren en tevens is de test geschikt voor loopobservatie gedurende langere tijd.^335-337 De werkgroep raadt aan om bij het afnemen van de 6MINWT ook de Borgschaal 6-20 te gebruiken om direct inzicht te verkrijgen in de door de patiënt ervaren inspanning.^338,339

Het gebruik van een loopband is niet aan te bevelen voor de 6MINWT, omdat patiënten op een loopband niet goed hun eigen tempo kunnen bepalen.³³⁶

De werkgroep raadt aan de 6MINWT te gebruiken als uit de Intakevragenlijst blijkt dat de persoon weinig actief is. Als de patiënt tijdens de 6MINWT maar een korte afstand kan afleggen, is verder onderzoek nodig naar de oorzaak van de stoornis.

Daarbij dient ook gekeken te worden naar de spiersterkte. Het kan in dat geval ook zinvol zijn om de longfunctie, hartfunctie, enkel-armindex, voedingstoestand en cognitieve functie en het functioneren van het steun- en bewegingsapparaat te controleren.³³⁶ Als de 6MINWT gebruikt wordt om veranderingen in het uithoudingsvermogen bij te houden, dient daarbij de absolute verandering in meters te worden geregistreerd.

 

Tien Meter Looptest (10MLT)

Aandachtsgebied: lopen

Loopsnelheid is van belang voor de veiligheid, bijvoorbeeld bij het oversteken van de straat. Met de 10MLT kan de loopsnelheid bij zowel een comfortabel als een hoog looptempo beoordeeld en geëvalueerd worden.¹¹¹ Deze test is ook geschikt voor het bepalen van de schredelengte en de cadans (stapfrequentie).

De schredelengte is van belang als het gebruik van visuele cues overwogen wordt en de cadans is van belang als het gebruik van auditieve cues overwogen wordt (paragraaf C.2.2). Patiënten mogen bij deze test een loophulpmiddel gebruiken. De 10MLT is niet gevalideerd om lopen met een dubbeltaak te evalueren, maar dubbeltaken gebruiken tijdens de 10MLT helpt wel om vast te stellen of een patiënt een verhoogd valrisico  heeft.

Bij ruimtegebrek kan de 10MLT worden ingekort tot 6 meter (6MLT). De 6MLT is echter niet gevalideerd voor het meten van veranderingen.

 

Activities-specific Balance Confidence (ABC) Scale

Aandachtsgebied: balans

Op de ABC Scale geven patiënten voor verschillende activiteiten aan hoeveel vertrouwen ze hebben dat ze die activiteit kunnen uitvoeren zonder hun balans te verliezen.³⁴⁰

De ABC Scale helpt bij het vaststellen van een verhoogd valrisico³⁴¹ en kan ook gebruikt worden om eventuele verandering vast te stellen. Daarnaast is de score op de ABC Scale een bepalende factor voor de functionele wandelcapaciteit, die gemeten wordt met de 6MINWT.²⁵⁵

 

Berg Balance Scale (BBS)

Aandachtsgebied: balans

De BBS beoordeelt beperkingen in activiteiten bij het uitvoeren van functionele taken die een beroep op de balans doen.³⁴² De BBS helpt bij het vaststellen of een patiënt een verhoogd valrisico heeft. Een nadeel van de BBS is dat veel patiënten met de ziekte van Parkinson de maximale score behalen. Een mogelijke verklaring voor dit plafondeffect is dat de BBS freezing en parkinsonspecifieke beperkingen in activiteiten bij het uitvoeren van dubbeltaken niet betrekt bij beoordeling.

Ook wordt het lopen niet beoordeeld. De werkgroep raadt daarom aan de BBS alleen te gebruiken bij patiënten in een gevorderd stadium van de ziekte, die minder mobiel zijn en vooral in stilstand balansproblemen hebben.

 

Borgschaal 6-20

Aandachtsgebied: fysieke capaciteit

Met de Borgschaal 6-20 kan inzicht verkregen worden in de ervaren inspanning.³³⁸ Dit meetinstrument geeft bij gezonde mensen van middelbare leeftijd en ouderen een goed beeld van de inspanningsintensiteit en laat bij deze populaties een goede correlatie zien met fysiologische criteria, zoals de hartslag.^339,343

De validiteit, betrouwbaarheid en hanteerbaarheid van de Borgschaal 6-20 zijn niet apart onderzocht bij patiënten met de ziekte van Parkinson, maar volgens de werkgroep is er geen reden om dit meetinstrument niet te gebruiken.

 

Dynamic Gait Index (DGI) en de Functional Gait Assessment (FGA)

Aandachtsgebied: balans

Met de DGI en de FGA kan zowel de statische als de dynamische balans beoordeeld worden. Beide tests beschikken over goede psychometrische kenmerken, zijn goed toepasbaar en helpen achterhalen of de patiënt een verhoogd valrisico heeft. Voor de DGI is zelfs een afkapwaarde vastgesteld voor de aanwezigheid van een verhoogd valrisico en dit meetinstrument kan gebruikt worden om eventuele veranderingen bij te houden.

Bij de DGI wordt een score gegeven voor de balans tijdens het uitvoeren van acht loopactiviteiten.^344,345 De scores voor afzonderlijke testitems helpen bij het vaststellen van onderliggende stoornissen, zoals gebrekkige dynamische controle van het lichaamszwaartepunt of afwijkende gewichtsverdeling. Deze informatie is van belang bij het bepalen van de behandeldoelen en het kiezen van een interventie.

De FGA wordt gezien als een verbeterde versie van de DGI. De FGA neemt ook het achteruitlopen mee in de beoordeling, maar vereist wel een tijdrovende voorbereidingsprocedure, omdat er eerst tapemarkeringen moeten worden aangebracht.

Aangezien de FGA en de DGI veel vergelijkbare items bevatten, kunnen ze gecombineerd worden. De FGA bevat drie extra activiteiten en geeft daarmee extra duidelijkheid over het al dan niet aanwezig zijn van een verhoogd valrisico.³⁴⁵ Vooral het achteruitlopen levert waardevolle informatie op over de balans bij stoeltransfers. De werkgroep adviseert om de tests tijdens een off-fase uit te voeren om nauwkeuriger te kunnen vaststellen of er sprake is van een verhoogd valrisico.³⁴⁶

 

Falls Efficacy Scale International (FES-I)

Aandachtsgebied: balans

Bij minder mobiele patiënten kan overwogen worden om in plaats van de ABC Scale de FES-I te gebruiken.³⁴⁷ Als de fysiotherapeut maar weinig tijd heeft, kan gekozen worden voor de verkorte versie, de Short FES-I (de items 2, 4, 6, 7, 9, 15 en 16 van de oorspronkelijke FES-I).

De FES-I geeft echter meer inzicht in de angst om te vallen tijdens binnen- en buitenactiviteiten dan de Short FES-I en levert dus meer informatie op ten aanzien van behandeldoelen en de meest geschikte interventie. Bovendien is er maar weinig bekend over de psychometrische kenmerken van het gebruik van de FES-I bij parkinson.

 

Five Times Sit to Stand (FTSTS)

Aandachtsgebieden: fysieke capaciteit en transfers

De FTSTS is een snel uit te voeren test van de functionele bewegingen en helpt bij het vaststellen van onvoldoende beenspiersterkte en -uithoudingsvermogen. Tevens is de test geschikt om de balans te testen bij een stoelgerelateerde transfer en om te beoordelen of de patiënt een verhoogd valrisico heeft.³⁴⁸

Bij deze test wordt bekeken in hoeveel tijd de patiënt kan opstaan uit een 43 cm hoge stoel. De werkgroep raadt het gebruik van de FTSTS, in combinatie met de Push and Release (P&R) Test aan voor patiënten bij wie onzekerheid bestaat over hun balans bij transfers. De FTSTS levert geen gedetailleerde informatie op over balansproblemen tijdens het lopen en in stilstand.

 

Gemodificeerde Parkinson Activiteiten Schaal (M-PAS)

Aandachtsgebieden: transfers, balans en lopen

De Gemodificeerde M-PAS beoordeelt de kwaliteit van en de beperkingen in functionele bewegingen.³⁴⁹ De M-PAS test drie functionele bewegingen: ‘transfer stoel’, ‘gangakinesie’ en ‘bedmobiliteit’. In het onderdeel Gangakinesie wordt ook de Timed Up and Go (TUG) uitgevoerd. Deze test kan gedaan worden met een motorische dubbeltaak (al lopend een dienblad met bekers water dragen) of met een cognitieve dubbeltaak (al lopend terugtellen).

Door bij te houden hoeveel tijd de activiteit kost, kan de TUG ook daadwerkelijk gescoord worden (het is dan van belang om de ‘U’ op 3 meter te vervangen door een pilon (immers zonder de draai in een ‘nieuwe U’ zullen sommige patiënten sneller lopen en is het niet zuiver de TUG).

Het is belangrijk dat de patiënt elke keer hetzelfde schoeisel draagt.³⁵⁰ De bedmobiliteit wordt met en zonder gebruik van een deken getest. De M-PAS levert belangrijke informatie op bij het bepalen van de behandeldoelen en het kiezen van een interventie.

Welke onderdelen van de test gebruikt worden, hangt af van de ervaren problemen.

• Voor beoordeling van de balans worden de onderdelenTransfer stoel en Gangakinesie aanbevolen;
• ter beoordeling van de kwaliteit van stoel- of bedgerelateerde transfers raadt de werkgroep de onderdelen Transfer stoel en Bedmobiliteit aan;
• ter beoordeling van de loopkwaliteit wordt het onderdeel Gangakinesie aangeraden.

Logboek bewegen

Aandachtsgebied: fysieke capaciteit

In het Logboek bewegen houdt de patiënt een week bij hoeveel minuten hij aan bepaalde activiteiten besteedt. Tevens kan de mate van inspanning middels de Borgschaal genoteerd worden.³³⁸ Het Logboek bewegen kan ter inventarisatie en ter evaluatie worden gebruikt.

 

Mini Balance Evaluation Systems Test (Mini-BESTest)

Aandachtsgebied: balans

Met de Mini-BESTest kan zowel de statische als de dynamische balans beoordeeld worden.³⁵¹Enkele testonderdelen zijn de TUG, de Push and Release (P&R) Test en de loopkwaliteit tijdens het veranderen van loopsnelheid, het ontwijken van obstakels en het draaien om de as.

De Mini-BESTest beschikt over goede psychometrische kenmerken, is goed toepasbaar en is te gebruiken om veranderingen bij te houden.³⁵² Voor de Mini-BESTest is tevens een afkapwaarde vastgesteld voor de aanwezigheid van een verhoogd valrisico.

 

Nine-hole Peg Test

Aandachtsgebied: arm- en handvaardigheid

Voor het beoordelen van het dragen, verplaatsen of vastpakken kunnen geen specifieke meetinstrumenten worden aanbevolen. Het enige meetinstrument op dit gebied waarvan de validiteit, betrouwbaarheid en responsiviteit gevalideerd zijn voor gebruik bij parkinson is de Nine-hole Peg Test.³⁵³

Hiermee worden nauwkeurige hand- en vingerbewegingen beoordeeld. Deze test kan gebruikt worden ter evaluatie van training van de fijne motoriek van de handen. De Nine-hole Peg Test geeft echter geen inzicht in de kwaliteit van de uitvoering en in de aandachtsgebieden voor fysiotherapeutische interventie.

Bovendien moet voor het gebruik van deze test betaald worden. De werkgroep raadt daarom aan om deze test alleen te gebruiken als die al voorhanden is op de behandellocatie (ziekenhuizen met een afdeling ergotherapie beschikken vaak over deze test).

 

Push and Release (P&R) Test

Aandachtsgebied: balans

De P&R Test beoordeelt de balanscontrole tijdens het stilstaan.³⁵⁴ Deze test geeft inzicht in onwillekeurige bewegingsreacties die een rol spelen bij het bewaren van de balans wanneer de patiënt achteruitloopt (bijvoorbeeld bij het openen van een deur of het gaan zitten) en bij lopen op een gladde ondergrond. De retropulsietest (opgenomen in de Unified Parkinson’s Disease Rating Scale van de Movement Disorder Society, de MDS-UPDRS³²³) is onder neurologen en fysiotherapeuten bekender.

Bij die test worden balansproblemen vastgesteld door te controleren hoe goed patiënten hun balans kunnen hervinden na een plotselinge achterwaartse ruk. De P&R Test is echter gevoeliger tijdens off-fasen en beter toepasbaar bij kwetsbare patiënten en beschikt daarnaast over een betere indruksvaliditeit voor gebruik binnen de fysiotherapeutische zorg.

 

Rapid Turns test

Aandachtsgebied: balans

Voor patiënten die op de Intakevragenlijst hebben aangegeven last te hebben van freezing, is het zinvol om naast de NFOG-Q, de Rapid Turns Test te gebruiken. Deze test lokt freezing uit.²⁷² De patiënt wordt gevraagd om herhaaldelijk helemaal om zijn as te draaien, in beide richtingen, met hoge snelheid en een kleine draaicirkel.²⁷² Als het niet lukt om op deze manier freezing uit te lokken, kunnen er dubbeltaken worden toegevoegd. Vaak is het lastig om festinatiestappen die aan freezing voorafgaan te onderscheiden van pure festinatie, die niet door freezing wordt gevolgd.³¹⁹

Om vast te stellen of de patiënt vrijwillig stopt of last heeft van freezing, beoordeelt de fysiotherapeut of de volgende kenmerken van freezing aanwezig zijn:³¹⁹

• een gebogen houding met vaste flexie in de heup-, knie- en enkelgewrichten;
• onvolledig tot stilstand komen, waarbij de patiënt op de plaats natrilt of schuifelpasjes naar voren maakt;
• in veel gevallen: voorafgaand aan de freezing steeds kleiner wordende stappen en een toenemende cadans;
• het gevoel hebben aan de grond genageld te staan.

Timed Up and Go (TUG)

Aandachtsgebieden: transfers, balans en lopen

De TUG is een korte test die een vermogensmaat voor functionele bewegingen oplevert.³⁵⁵ De TUG is geschikt om loopsnelheid in het kader van functionele bewegingen te beoordelen. Daarnaast helpt de TUG om een eventueel valrisico vast te stellen (hoe langer de duur, hoe groter de kans op een verhoogd valrisico).

Om nauwkeuriger te kunnen vaststellen of iemand een verhoogd valrisico heeft, adviseert de werkgroep de TUG tijdens de off-fase uit te voeren.³⁴⁶ De werkgroep raadt bovendien aan om niet alleen de benodigde tijd te beoordelen, maar ook te noteren hoe veilig de persoon zich omdraait.

NB De TUG kan gecombineerd worden met de Gemodificeerde Parkinson Activiteiten Schaal (M-PAS) (in het onderdeel Gangakinesie) en de Balance Evaluation Systems Test (Mini-BESTest).

 

Valagenda

Aandachtsgebied: balans

De Valagenda is bedoeld om inzicht te krijgen in de valfrequentie, de omstandigheden waaronder de valincidenten plaatsvinden en de mogelijke oorzaken ervan en wordt aanbevolen voor gebruik in de klinische praktijk.³⁵⁶ De werkgroep raadt fysiotherapeuten aan om de Valagenda mee te geven aan patiënten die vermoedelijk een verhoogd valrisico hebben. Indien van toepassing, dient de Valagenda samen met de mantelzorger te worden ingevuld.

 

Valpredictiemodel

Valpredictiemodel 

Aandachtsgebied: balans

Of een op valpreventie gerichte interventie nodig is, is goed vast te stellen aan de hand van gegevens over vallen, freezing en de comfortabele loopsnelheid. Met het Valpredictiemodel wordt beoordeeld of de patiënt een laag, matig of hoog risico heeft om binnen zes maanden na afname van de test te vallen (met respectievelijk de volgende absolute risico’s: 17%, 51% en 85%).²⁶⁹ Deze uitkomst helpt bepalen of er een indicatie is voor interdisciplinaire beoordeling, individuele fysiotherapeutische behandeling of dat deelname aan een algemene beweeggroep mogelijk is.

De werkgroep wil benadrukken dat bij de besluitvorming niet alleen naar de afkapscore gekeken moet worden, maar juist naar het complete klinische beeld:

• eventuele aanwezigheid van freezing;^269,277,357
• eventuele aanwezigheid van dementie;^233,358
• eventuele aanwezigheid van (lichte) cognitieve stoornissen, bijvoorbeeld in het werkgeheugen en de responsgeneratie;^359,360
• eventuele aanwezigheid van urine-incontinentie;²⁵⁶
• eventuele verminderde armzwaai;²³³
• het item van de UPDRS dat is gericht op snel wisselende taken;³⁶¹
• eventuele verminderde aandacht en executieve functies;^362,363
• het aantal jaren sinds diagnosticering;²³³
• externe factoren, zoals te veel meubelen in huis, gladde vloer, losliggend tapijt, slechte verlichting en ongeschikt schoeisel;
• eventuele bijwerkingen van medicatie (Addendum Praktijk, hoofdstuk 3), zoals hallucinaties;
• eventuele comorbiditeiten, zoals diabetische neuropathie;
• de frequentie en veiligheid van alledaagse activiteiten (zoals multitasken).

Afkapscores zeggen meestal iets over het valrisico voor de komende drie tot zes maanden.³⁶⁴

De gevoeligheid van een afkapscore geeft aan hoeveel procent van de patiënten met een verhoogd valrisico, ook daadwerkelijk als zodanig wordt aangewezen door het betreffende meetinstrument. Dus hoe hoger het gevoeligheidspercentage van de afkapscore, hoe groter de kans dat het betreffende meetinstrument bij een patiënt terecht een verhoogd valrisico vaststelt.

De kans dat terecht een verhoogd valrisico wordt vastgesteld, is bij een patiënt met een score op de Activities-specific Balance Confidence (ABC) Scale van 65% bijvoorbeeld groter dan bij een patiënt die in het voorgaande jaar één keer gevallen is, aangezien de gevoeligheid bij deze bevindingen respectievelijk 93% en 77% is. 

Vaak worden bij een patiënt meerdere meetinstrumenten gebruikt. Als de scores van meerdere meetinstrumenten boven de bijbehorende afkapwaarde vallen, zal de gevoeligheid waarschijnlijk nog hoger zijn dan in de tabel vermeld wordt voor de afzonderlijke scores. De afkapscores kunnen dus een waardevol hulpmiddel zijn in de klinische praktijk. In de volgende tabel staat van verschillende aanbevolen en optionele meetinstrumenten de afkapscore.

Afkapscores die inzicht geven in het valrisico bij de ziekte van Parkinson.

Meetinstrument	Aantal  patiënten	H&Y-score, spreiding/gemiddelde	Afkapscore	Gevoeligheid (%) AUC of OR
Valgeschiedenis (voorgaande 12 maanden)	349 113 109	1-5 / 2,4 1-3 / ? 1-4 / ?	≥ 1 valincident ≥ 1 valincident	77%232 77%, OR 5,36357 OR 4,0233
ABC Scale	20 49 122	2,9 / ? 2-3 / ? ? / 2,8	< 69% < 76% < 80%	93%253 84%, AUC 0,76341 OR 0,06 voor niet-vallers255
DGI	45 49 70	2-3 / 2,6 ? / 2-3 1-4 / 2,3	≤ 22 < 19 ≤ 19	89%365 68%, AUC 0,76341 64%366
FGA	80 80	1-4 / 2,5 1-4 / 2,4	≤ 15/30 ≤ 15/30	72%, AUC 0,80367 voorspellend: 64%a AUC 0,80a,364
BBS	49 70 80 80 45	2-3 / ? 1-4 / 2,3 1-4 / 2,5 1-4 / 2,4 2-3 / 2,6	< 44 ≤ 45 ≤ 47 ≤ 47 ≤ 54	68%, AUC 0,85, OR 48,9341 64%366 72%, AUC 0,79367 voorspellend: 79% AUC 0,87a, 364 79%365
Mini-BESTest	80b 97 8 110	1-4 1-4 2,4	< 20 < 22 < 21 < 19	88%368 89%369 voorspellend: AUC 0,87a, 86%a; AUC 0,77c, 62%c, 364 79% AUC 0,75370
FTSTS	82	1-4 / 2,4	> 16 sec	75%, AUC 0,77371
TUG	45 70 122	2-3 / 2,6 1-4 / 2,3 ? / 2,8	≥ 7,95 sec ≥ 8,5 sec ≥ 16 sec	93%365 68%366 OR 3,86255
10MLTd	78	1-4 / 2,6	< 0,98 m/sec	80%; AUC 0,80268
Valpredictiemodel	205	1-4 / 2,6	10MLTa <1,1 m/sec en ≥ 1 valincident/12 mnd  en freezing in voorgaande maand	AUC 0,80 (95%-BI 0,73-0,86)a, 269
10MLT = Tien Meter Looptest; ABC Scale = Activities-specific Balance Confi dence Scale; BBS = Berg Balance Scale; DGI = Dynamic Gait Index; FGA = Functional Gait Assessment; FTSTS = Five Times Sit To Stand; Mini-BESTest = Mini Balance Evaluation Systems Test; TUG = Timed Up and Go. H&Y = Hoehn en Yahr. ? = onbekend. AUC = area under the curve: een AUC-waarde > 0,70 voldoet; OR = oddsratio: hoeveel keer groter de kans is dat patiënten met een score boven de afkapwaarde terecht als ‘vallers’ worden aangemerkt. a Voorspellend voor de komende zes maanden. b n = 29 niet beschikbaar voor follow-up. c Voorspellend voor de komende 12 maanden. d Comfortabele, zelf verkozen loopsnelheid.

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