Referral to rehabilitation in Parkinson's disease: who,
          when and to what end?

Domingos, Josefa; Coelho, Miguel; Ferreira, Joaquim J

doi:10.1590/0004-282X20130209

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TRICKS OF THE TRADE • Arq. Neuro-Psiquiatr. 71 (12) • 01 Dec 2013 • https://doi.org/10.1590/0004-282X20130209 copy

Referral to rehabilitation in Parkinson's disease: who, when and to what end?

Critérios de encaminhamento para a reabilitação na doença de Parkinson: quem, quando e que finalidade?

Authorship SCIMAGO INSTITUTIONS RANKINGS

The current state of evidence in non-pharmacological treatments amounts to an impending paradigm shift in neurology where physicians should be alerted that some rehabilitation interventions are already supported in current therapeutic guidelines. This manuscript aims to overview the best scientific data supporting referral to rehabilitation services in order to help physicians make the best use of the existing evidence for non-pharmacological treatments in the different stages of Parkinson´s disease.

Parkinson's disease; non-pharmacological treatments; physical therapy; speech therapy; rehabilitation

Non-pharmacological therapies
Main key therapies
Nurse PD specialist
Physical therapy
Speech and language therapy
Occupational therapy
Others
Dietician
Social worker
Sexologist
Psychologist
Complementary therapies such as: Tai Chi, Quigong, Massage, Acupuncture and Nutritional supplements.
Hydrotherapist
Psychiatrist
Music Therapist
Patient Associations

Motor problems
Problem domain	Treatment interventions	Guidelines and level of evidence	Implications for referral
Transfers & Mobility Problems	Strategy training with cueing.	KNGF [11] – Level II	Physical therapy should be considered to address motor impairments in transfers & mobility.
		MDS [6] – Level II
	Cognitive movement strategy training for daily activities and transfers.	KNGF [11] – Level II
	Movement initiation training.	NICE [4] – Level II
	Training functional independence, including mobility and activities of daily living.	NICE [4] – Level II
	Alexandre Technique.	NICE [4] – Level III
	Advice regarding safety in the home environment.	NICE [4] – Level II

Gait disturbances	Gait re-education.	NICE [4] – Level II	Physical therapy should be considered to address motor impairments in balance, gait, physical capacity, falls and freezing. Tai chi and Qigong may be considered for balance and gait impairments.
	Cued training and strategies.	EFNS/ MDS [3] – Level II
	Cued training for dual task.	EFNS/ MDS [3] – Level III
	Treadmill training for gait speed.	EFNS/ MDS [3] – Level II
	Exercise - based interventions.	EFNS/ MDS [3] – Level II
Physical capacity	Aerobic exercise.	NICE [4] – Level II
Physical capacity		EFNS/ MDS [3] – Level II
Postural instability and balance problems	Treadmill training.	MDS [6] – Level II
		EFNS/ MDS [3] – Level II
	Physical activity and exercise.	MDS [6] – Level II
		EFNS/ MDS [3] – Level II
	Balance training.	NICE [4] – Level II
	Tai Chi or Qigong.	EFNS/ MDS [3] – Level II
Falls and fear of falling	General elderly recommendations.	EFNS/ MDS [3] – Level IV
	Physical activity and exercise for near falls.	MDS [6] – Level II
		EFNS/ MDS [3] – Level II
	Physical activity and exercise for falls.	MDS [6] – Level III
		EFNS/ MDS [3] – Level II

Freezing	Cueing training in the home.	MDS [6] – Level II	Physical therapy should be considered for cueing training for freezing.
		EFNS/ MDS [3] – Level II
	Visual or auditory cues	MDS [6] – Level III
		EFNS/ MDS [3] – Level III
	Combining treadmill training and cueing.	MDS [6] – Level II
		EFNS/ MDS [3] - Level II

Speech impairment	Lee Silverman Voice Therapy (LSVT).	NICE [4] – Level II	Speech therapy using LSVT may be considered to address motor complications regarding vocal intensity and phonation of speech.
		MDS [6] – Level II
		EFNS/ MDS [3] – Level II
	Pitch Limiting Voice Treatment (PLVT)	MDS [6] – Level IV
		EFNS/ MDS [3] – Level IV
	Teaching strategies to optimise speech intelligibility.	NICE [4] – Level IV
	Use of assistive technologies.	NICE [4] – Level IV

Non motor problems
Problem domain	Treatment interventions	Guidelines and level of evidence	Implications for referral
Orthostatic hypotension	General recommendations.	MDS [6] – Level IV	General measures may be addressed by any of the multidisciplinary team members for non-motor problems such as orthostatic hypotension, nocturia, constipation, daytime somnolence, REM sleep behaviour disorder and good sleep hygiene.
		EFNS/ MDS [3] – Level IV
Urinary disturbance	General measures for treating nocturia.	MDS [6] – Level IV
		EFNS/ MDS [3] – Level IV
Gastrointestinal motility	General recommendations for constipation.	MDS [6] – Level IV
		EFNS/ MDS [3] – Level IV

Dysphagia	Speech therapy for assessment, swallowing advice and further instrumental investigations.	MDS [6] – Level IV	Speech therapy for assessment and swallowing advice may be considered for dysphasia and drooling.
	Advice on modification of food/drink.	EFNS/ MDS [3] – Level IV
	Management to support safety and efficiency of swallowing and minimize risk of aspiration.	NICE [4] – Level IV
Excessive saliva and drooling	Behavioral management techniques.	NICE [4] – Level IV

Sleep disorders	General measures for treatment of daytime somnolence in PD.	NICE [4] – Level IV	General measures may be addressed by any of the multidisciplinary team members for non-motor problems such as daytime somnolence, REM sleep behaviour disorder, good sleep hygiene and pain.
		MDS [6] – Level IV
	In REM sleep behaviour disorder in PD, methods of self-protection.	MDS [6] – Level IV
	Good sleep hygiene.	NICE [4] – Level IV
		MDS [6] – Level IV
Pain	Generic management.	NICE [4] – Level IV

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[1] Correspondence : Joaquim J Ferreira; Laboratório de Farmacologia Clínica e Terapêutica / Faculdade de Medicina de Lisboa; Av. Prof. Egas Moniz 1649-028; Lisboa, Portugal; E-mail:joaquimjferreira@gmail.com