Parkinson's disease is a complex, progressive, multi-system disease associated with motor, cognitive and emotional impairments. On the basis of a review of evidence-based Parkinson's disease guidelines and systematic reviews of non-pharmacological and non-surgical treatments, Domingos and colleagues11 . Domingos J, Coelho M, Ferreira JJ. Referral to rehabilitation in Parkinson's disease: who, when and to what end? Arq Neuropsiquiatr 2013;71:967-972. offer a timely opinion statement providing physicians with guidelines promoting referral of people with Parkinson's disease to rehabilitation services.
It is clear that the evidence-base for rehabilitation, in particular for physical
interventions, ie, physiotherapy and/or exercise22 . Tomlinson CL, Patel S, Meek C, et al. Physiotherapy versus placebo
or no intervention in Parkinson's disease. Cochrane Database Syste Rev
2012;7:CD002817.
3 . Tomlinson CL, Patel S, Meek C, et al. Physiotherapy intervention
in Parkinson's disease: systematic review and meta-analysis. BMJ
2012;345:e5004.
4 . Rochester L, Nieuwboer A, Lord S. Physiotherapy for
Parkinson's disease: defining evidence within a framework for intervention.
Neurodegenerat Dis Manag 2011;1:57-65.
-
55 . Earhart GM, Falvo MJ. Parkinson disease and exercise. Compr
Physiol 2013;3:833-848., is continuing to expand exponentially44 . Rochester L, Nieuwboer A, Lord S. Physiotherapy for
Parkinson's disease: defining evidence within a framework for intervention.
Neurodegenerat Dis Manag 2011;1:57-65.
,
66 . Keus SH, Munneke M, Nijkrake MJ, Kwakkel G, Bloem BR., Physical
therapy in Parkinson's disease: evolution and future challenges. Mov Disord
2009;24:1-14.. However, implementing the evidence is challenging, as questions remain
regarding optimal modes of physical interventions and optimal dose and intensity of
exercise. Domingos and colleagues11 . Domingos J, Coelho M, Ferreira JJ. Referral to rehabilitation in
Parkinson's disease: who, when and to what end? Arq Neuropsiquiatr
2013;71:967-972. (in Figure 1) illustrate the complexities of the available interventions and the
potential of some interventions to addresses more than one motor problem. The allied
health professionals who deliver rehabilitation interventions are autonomous
professionals trained in evidence-based practice and are first-contact practitioners
(not requiring a referral from a medical practitioner) in many countries, including
Brazil. While it is the responsibility of the physician to facilitate referral, it is
the responsibility of rehabilitation professionals to assess the person with
Parkinson's disease and to collaboratively with the patient decide upon treatment
goals and intervention, based on their evidence-informed judgement. This involves
consideration of not only the presenting motor impairments and activity limitations, but
also non-motor impairments such as cognitive impairment, disease stage, co-morbidities,
as well as exercise history, exercise-self efficacy and individual preferences77 . Ellis T, Boudreau JK, DeAngelis TR, et al. Barriers to exercise in
people with Parkinson disease. Phys Ther 2013;93:628-636.
,
88 . Ellis T, Cavanaugh JT, Earhart GM, et al. Factors associated with
exercise behavior in people with Parkinson disease. Phys Ther
2011;91:1838-1848.. Although very few serious adverse effects associated with rehabilitation
interventions have been reported99 . Allen NE, Sherrington C, Suriyarachchi GD, Paul SS, Song J,
Canning CG. Exercise and motor training in people with Parkinson's disease:
a systematic review of participant characteristics, intervention delivery,
retention rates, adherence and adverse events in clinical trials. Parkinson Dis
2012:ID854328., the relative risks and benefits of rehabilitation interventions also need to
be assessed, particularly with respect to the level of supervision required for physical
interventions.
There is a move towards a more collaborative model of healthcare, ie, patient-centred
care, where the patient actively participates in making decisions about their individual
health care rather than passively accepting the prescription of the health care
professional1010 . van der Eijk M, Nijhuis FA, Faber MJ, Bloem BR. Moving from
physician-centered care towards patient-centered care for Parkinson's
disease patients. Parkins Relat Disord 2013;19:923-927.. This model is particularly well-suited to delivering rehabilitation
interventions to people with Parkinson's disease, where several interventions are
evidence-based, but there is no evidence to indicate which intervention is best. For
example, if one of the goals of rehabilitation is to improve aerobic exercise capacity,
there is currently supporting evidence for group aerobic exercise1111 . Bridgewater KJ, Sharpe MH. Aerobic exercise and early
Parkinson's disease. Neurorehabilitation Neural Repair
1996;10:233-241., cycle ergometry1212 . Bergen JL, Toole T, Elliot RG 3rd, Wallace B, Robinson K, Maitland
CG. Aerobic exercise intervention improves aerobic capacity and movement
initiation in Parkinson's disease patients. Neuro
Rehab2002;17:161-168.
,
1313 . Schenkman M, Hall DA, Barón AE, Schwartz RS, Mettler P, Kohrt WM.
Exercise for people in early- or mid-stage Parkinson disease: a 16-month
randomized controlled trial. Phys Ther 2012;92:1395-1410. and treadmill walking1212 . Bergen JL, Toole T, Elliot RG 3rd, Wallace B, Robinson K, Maitland
CG. Aerobic exercise intervention improves aerobic capacity and movement
initiation in Parkinson's disease patients. Neuro
Rehab2002;17:161-168.
13 . Schenkman M, Hall DA, Barón AE, Schwartz RS, Mettler P, Kohrt WM.
Exercise for people in early- or mid-stage Parkinson disease: a 16-month
randomized controlled trial. Phys Ther 2012;92:1395-1410.
-
1414 . Shulman LM, Katzel LI, Ivey FM, et al. Randomized clinical trial
of 3 types of physical exercise for patients with Parkinson's disease. JAMA
Neurol 2013;70:183-190.. Using the patient-centred healthcare model, the individual patient and his/her
rehabilitation professionals jointly consider the evidence, the patient's goals and
preferences for exercise, as well as pragmatics, such as access to exercise programs,
equipment and cost. Additional benefits include the potential to maximize the
patient's adherence to the exercise program, collaborative monitoring and
modification of the program, as well as development of self-management strategies. The
European Physiotherapy Guideline for Parkinson's disease (currently in draft form)
provides further information on the implementation of these strategies1515 . Keus SHJ, Munneke M, Graziano M, et al. European Physiotherapy
Guideline for Parkinson's disease (For Review) 2013; available at
http://www.parkinsonnet.info/media/11928217/eu_20physiotherapy_20guideline_20pd_review_2020131003-1.pdf
(accessed 4 November 2013).
http://www.parkinsonnet.info/media/11928...
; incorporating interdisciplinary collaboration with key rehabilitation
professionals, including Parkinson's disease nurses, occupational therapists and,
speech and language therapists.
There will always be a lag between emerging gold-standard evidence from randomised
controlled trials and the guidelines and systematic reviews based on this evidence.
For example, the recommendations of the European Federation of Neurological Societies
and Movement Disorder Society-European Section (EFNS/MDS-ES) review on therapeutic
management of Parkinson's disease published in 20131616 . Ferreira JJ, Katzenschlager R, Bloem BR, et al. Summary of the
recommendations of the EFNS/MDS-ES review on therapeutic management of
Parkinson's disease. Eur J Neurol 2013;20:5-15. included studies up to the end of 2010. More recently-published randomised
controlled trials provide evidence supporting additional modes of physical interventions
including Tai-Chi1717 . Li F, Harmer P, Fitzgerald K, et al. Tai chi and postural
stability in patients with Parkinson's disease. N Engl J Med
2012;366:511-519., tango dancing1818 . Duncan RP, Earhart GM. Randomized controlled trial of
community-based dancing to modify disease progression in Parkinson disease.
Neurorehab Neural Repair 2012;26:132-143., Irish set dancing1919 . Volpe D, Signorini M, Marchetto A, Lynch T, Morris ME. A
comparison of Irish set dancing and exercises for people with Parkinson's
disease: a phase II feasibility study. BMC Geriatr 2013;13:54., muscle strengthening exercises2020 . Corcos DM, Robichaud JA, David FJ, et al. A two-year randomized
controlled trial of progressive resistance exercise for Parkinson's
disease. Mov Disord 2013;28:1230-1240. and muscle power training2121 . Paul SS, Canning CG, Song J, Sherrington C, Fung VSC. Leg muscle
power is enhanced by training in people with Parkinson's disease: a
randomised controlled trial. Clin Rehab 2013; published online 4 November 2013,
DOI:10.1177/0269215513507462.
https://doi.org/10.1177/0269215513507462...
. In addition, a multifaceted behavioural change physiotherapy intervention
designed to increase physical activity has been shown to have some benefits on physical
activity and walking capacity over and above those achieved by traditional
physiotherapy2222 . van Nimwegen M, Speelman AD, Overeem S, et al. Promotion of
physical activity and fitness in sedentary patients with Parkinson's
disease: randomised controlled trial. BMJ 2013;346:576.. Virtual reality gait training2323 . Mirelman A, Rochester L, Reelick M, et al. V-TIME: a treadmill
training program augmented by virtual reality to decrease fall risk in older
adults: study design of a randomized controlled trial. BMC Neurol
2013;13:15. and occupational therapy2424 . Sturkenboom IH, Graff MJ, Borm GF, et al. Effectiveness of
occupational therapy in Parkinson's disease: study protocol for a
randomized controlled trial. Trials 2013;14:34. are also currently being tested in large-scale randomised controlled trials.
Despite the exponential evolution of evidence for rehabilitation interventions, significant gaps remain. Motor impairments affecting the upper limbs, and non-motor impairments, such as depression and cognitive impairments are significant contributors to reduced quality of life in people with Parkinson's disease2525 . Soh SE, Morris ME, McGinley JL. Determinants of health-related quality of life in Parkinson's disease: a systematic review. Parkins Relat Disord 2011;17:1-9.. Therefore, there is an urgent need to explore the potential of rehabilitation interventions designed to address these impairments. There is also a paucity of research focusing on rehabilitation in late Parkinson's disease, particularly in Hoehn and Yahr stage 5 and this knowledge gap needs to be addressed.
The evidence of efficacy of rehabilitation for people with Parkinson's disease has been gained mostly from trials including predominantly early to mid-stage patients. Therefore, the strongest evidence supports the delivery of rehabilitation interventions early in the disease process, when rehabilitation can play a key role in maintaining mobility and preventing secondary impairments of neuromuscular and cardiovascular systems associated with reduced physical activity. Many people with Parkinson's disease, particularly individuals with the Postural Instability Gait Disorder (PIGD) motor phenotype, will present with activity limitations in the early stages, even at their first visit to a neurologist2626 . Hariz GM, Forsgren L. Activities of daily living and quality of life in persons with newly diagnosed Parkinson's disease according to subtype of disease, and in comparison to healthy controls. Acta Neruol Scand 2011;23:20-27.. Despite this, in a recent large survey of 3405 physiotherapists from 17 European countries, a major barrier to delivery of optimal physiotherapy care was that referral to rehabilitation was initiated at too late a stage of disease progression2727 . Keus SH. Parkinson's care: insight into physiotherapy within Europe. Neurorehab Neural Repair 2012;26:707-708.. This finding further highlights the importance of Domingos and colleagues'11 . Domingos J, Coelho M, Ferreira JJ. Referral to rehabilitation in Parkinson's disease: who, when and to what end? Arq Neuropsiquiatr 2013;71:967-972. opinion statement promoting early referral to rehabilitation. Finally, although there is limited evidence to date, much research activity is currently underway exploring the role of exercise as a potential disease-modifying intervention for people with Parkinson's disease44 . Rochester L, Nieuwboer A, Lord S. Physiotherapy for Parkinson's disease: defining evidence within a framework for intervention. Neurodegenerat Dis Manag 2011;1:57-65. , 55 . Earhart GM, Falvo MJ. Parkinson disease and exercise. Compr Physiol 2013;3:833-848. , 2828 . Earhart GM, Ellis T, Nieuwboer A, Dibble E. Rehabilitation and Parkinson's disease. Parkinson Dis 2012;2012:371406. , 2929 . Petzinger GM, Fisher BE, McEwen S, Beeler JA, Walsh JP, Jakowec MW. Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson's disease. Lancet Neurol 2013;12:716-726.. If exercise is shown to have a disease-modifying effect, this would provide further support for routine referral of people to rehabilitation on diagnosis with Parkinson's disease.
References
-
1Domingos J, Coelho M, Ferreira JJ. Referral to rehabilitation in Parkinson's disease: who, when and to what end? Arq Neuropsiquiatr 2013;71:967-972.
-
2Tomlinson CL, Patel S, Meek C, et al. Physiotherapy versus placebo or no intervention in Parkinson's disease. Cochrane Database Syste Rev 2012;7:CD002817.
-
3Tomlinson CL, Patel S, Meek C, et al. Physiotherapy intervention in Parkinson's disease: systematic review and meta-analysis. BMJ 2012;345:e5004.
-
4Rochester L, Nieuwboer A, Lord S. Physiotherapy for Parkinson's disease: defining evidence within a framework for intervention. Neurodegenerat Dis Manag 2011;1:57-65.
-
5Earhart GM, Falvo MJ. Parkinson disease and exercise. Compr Physiol 2013;3:833-848.
-
6Keus SH, Munneke M, Nijkrake MJ, Kwakkel G, Bloem BR., Physical therapy in Parkinson's disease: evolution and future challenges. Mov Disord 2009;24:1-14.
-
7Ellis T, Boudreau JK, DeAngelis TR, et al. Barriers to exercise in people with Parkinson disease. Phys Ther 2013;93:628-636.
-
8Ellis T, Cavanaugh JT, Earhart GM, et al. Factors associated with exercise behavior in people with Parkinson disease. Phys Ther 2011;91:1838-1848.
-
9Allen NE, Sherrington C, Suriyarachchi GD, Paul SS, Song J, Canning CG. Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence and adverse events in clinical trials. Parkinson Dis 2012:ID854328.
-
10van der Eijk M, Nijhuis FA, Faber MJ, Bloem BR. Moving from physician-centered care towards patient-centered care for Parkinson's disease patients. Parkins Relat Disord 2013;19:923-927.
-
11Bridgewater KJ, Sharpe MH. Aerobic exercise and early Parkinson's disease. Neurorehabilitation Neural Repair 1996;10:233-241.
-
12Bergen JL, Toole T, Elliot RG 3rd, Wallace B, Robinson K, Maitland CG. Aerobic exercise intervention improves aerobic capacity and movement initiation in Parkinson's disease patients. Neuro Rehab2002;17:161-168.
-
13Schenkman M, Hall DA, Barón AE, Schwartz RS, Mettler P, Kohrt WM. Exercise for people in early- or mid-stage Parkinson disease: a 16-month randomized controlled trial. Phys Ther 2012;92:1395-1410.
-
14Shulman LM, Katzel LI, Ivey FM, et al. Randomized clinical trial of 3 types of physical exercise for patients with Parkinson's disease. JAMA Neurol 2013;70:183-190.
-
15Keus SHJ, Munneke M, Graziano M, et al. European Physiotherapy Guideline for Parkinson's disease (For Review) 2013; available at http://www.parkinsonnet.info/media/11928217/eu_20physiotherapy_20guideline_20pd_review_2020131003-1.pdf (accessed 4 November 2013).
» http://www.parkinsonnet.info/media/11928217/eu_20physiotherapy_20guideline_20pd_review_2020131003-1.pdf -
16Ferreira JJ, Katzenschlager R, Bloem BR, et al. Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson's disease. Eur J Neurol 2013;20:5-15.
-
17Li F, Harmer P, Fitzgerald K, et al. Tai chi and postural stability in patients with Parkinson's disease. N Engl J Med 2012;366:511-519.
-
18Duncan RP, Earhart GM. Randomized controlled trial of community-based dancing to modify disease progression in Parkinson disease. Neurorehab Neural Repair 2012;26:132-143.
-
19Volpe D, Signorini M, Marchetto A, Lynch T, Morris ME. A comparison of Irish set dancing and exercises for people with Parkinson's disease: a phase II feasibility study. BMC Geriatr 2013;13:54.
-
20Corcos DM, Robichaud JA, David FJ, et al. A two-year randomized controlled trial of progressive resistance exercise for Parkinson's disease. Mov Disord 2013;28:1230-1240.
-
21Paul SS, Canning CG, Song J, Sherrington C, Fung VSC. Leg muscle power is enhanced by training in people with Parkinson's disease: a randomised controlled trial. Clin Rehab 2013; published online 4 November 2013, DOI:10.1177/0269215513507462.
» https://doi.org/10.1177/0269215513507462 -
22van Nimwegen M, Speelman AD, Overeem S, et al. Promotion of physical activity and fitness in sedentary patients with Parkinson's disease: randomised controlled trial. BMJ 2013;346:576.
-
23Mirelman A, Rochester L, Reelick M, et al. V-TIME: a treadmill training program augmented by virtual reality to decrease fall risk in older adults: study design of a randomized controlled trial. BMC Neurol 2013;13:15.
-
24Sturkenboom IH, Graff MJ, Borm GF, et al. Effectiveness of occupational therapy in Parkinson's disease: study protocol for a randomized controlled trial. Trials 2013;14:34.
-
25Soh SE, Morris ME, McGinley JL. Determinants of health-related quality of life in Parkinson's disease: a systematic review. Parkins Relat Disord 2011;17:1-9.
-
26Hariz GM, Forsgren L. Activities of daily living and quality of life in persons with newly diagnosed Parkinson's disease according to subtype of disease, and in comparison to healthy controls. Acta Neruol Scand 2011;23:20-27.
-
27Keus SH. Parkinson's care: insight into physiotherapy within Europe. Neurorehab Neural Repair 2012;26:707-708.
-
28Earhart GM, Ellis T, Nieuwboer A, Dibble E. Rehabilitation and Parkinson's disease. Parkinson Dis 2012;2012:371406.
-
29Petzinger GM, Fisher BE, McEwen S, Beeler JA, Walsh JP, Jakowec MW. Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson's disease. Lancet Neurol 2013;12:716-726.
Publication Dates
-
Publication in this collection
01 Dec 2013
History
-
Received
05 Nov 2013 -
Accepted
12 Nov 2013