Beyond patient-centered care: person-centered care for Parkinson's disease

Effects of a sequential square mat walking training program Fisior® on improving physical performance in older adults with Parkinson's disease: A pilot study

BACKGROUND

This study aimed to assess the efficacy of a 12-week functional walking training program utilizing a sequential square mat (Fisior® Mat) on the physical performance of older adults diagnosed with Parkinson's Disease (PD).

METHODS

Participants, aged over 60 and diagnosed with mild to moderate PD, underwent progressive resistance training sessions lasting 30-40 minutes, three times a week, using the Fisior® sequential square mat. A randomized clinical trial was conducted with participants from a patient association. Multiple linear regression models were employed to analyze physical performance variation between intervention and control groups.

RESULTS

Twenty-eight patients (14 in each group) participated, with improvements observed in total Short Physical Performance Battery (SPPB) score, chair test score, gait speed score, and balance test score. Participants in the intervention group showed significant improvement in chair and balance test scores compared to controls.

CONCLUSION

The Fisior® sequential square mat program, as an adjunct to conventional outpatient physiotherapy, effectively enhances physical performance in older adults with PD.

Adherence to Non-Pharmacological Interventions in Parkinson's Disease: A Rapid Evidence Assessment of the Literature

Background

Low adherence to non-pharmacological interventions can impact treatment effectiveness. Yet, there is limited information on adherence barriers and facilitators to non-pharmacological interventions in Parkinson's disease (PD).

Objective

1) To examine the quality of adherence reporting and 2) to identify key determinants of adherence to PD non-pharmacological interventions.

Methods

A rapid evidence assessment was conducted, following PRISMA guidelines, that included controlled studies of exercise, physiotherapy, occupational therapy, speech-language therapy with explicit reporting of 'adherence' OR 'compliance', published in the last 15 years. Data extracted included: adherence rates, adherence outcomes, and factors associated with adherence. A collaborative thematic analysis was conducted to identify determinants of adherence.

Results

The search yielded 2,445 articles of which 114 met criteria for full screening with 45 studies meeting all inclusion criteria. High quality adherence data that aligned with the intervention goals were reported by 22.22%(N = 10) of studies, with the majority reporting attendance/attrition rates only 51.11%(N = 23). Four major themes (34 subthemes) emerged: disease and health, personal, program design, and system and environmental.

Conclusions

There has been limited progress in the quality of adherence reporting in PD non-pharmacological interventions over the last decade. Acknowledging this limitation, key determinants of adherence included: alignment with personal beliefs, attitudes, and expectations; the demands of the intervention and worsening disease symptoms and personal/time obligations; and accessibility and safety concerns. Program design elements found to facilitate adherence included: opportunities for social engagement and in-person offerings linked to higher levels of interventionist support, performative feedback, and social reinforcement.

Non-Pharmacological Interventions for Depression and Anxiety in Parkinson's Disease

Non-pharmacological interventions, including cognitive-behavioral therapy (CBT), non-invasive brain stimulation (NIBS), electroconvulsive therapy (ECT), light therapy (LT), and physical rehabilitation/exercise, have shown promise as effective approaches to treat symptoms of depression and anxiety in individuals with Parkinson's disease (PD). In this narrative literature overview, we discuss the state-of-the-art regarding these treatment options and address future perspectives for clinical practice and research. Non-pharmacological interventions hold promise to treat depression and anxiety in PD. There is meta-analytic evidence for the efficacy of CBT, NIBS, ECT, LT, and exercise on improving depressive symptoms. For the treatment of anxiety symptoms, CBT shows large effects but scientific evidence of other non-pharmacological interventions is limited. Importantly, these treatments are safe interventions with no or mild side-effects. More research is needed to tailor treatment to the individuals' needs and combined interventions may provide synergistic effects.We conclude that non-pharmacological interventions should be considered as alternative or augmentative treatments to pharmacological and neurosurgical approaches for the treatment of depression and anxiety in individuals with PD.

Clair KA, Toledo S, York MK, Todaro R, Yarab N, Wallock K. Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative disorder impacting everyday function and quality of life. Rehabilitation plays a crucial role in improving symptoms, function, and quality of life and reducing disability, particularly given the lack of disease-modifying agents and limitations of medications and surgical therapies. However, rehabilitative care is under-recognized and under-utilized in PD and often only utilized in later disease stages, despite research and guidelines demonstrating its positive effects. Currently, there is a lack of consensus regarding fundamental topics related to rehabilitative services in PD.

OBJECTIVE

The goal of the international Parkinson's Foundation Rehabilitation Medicine Task Force was to develop a consensus statement regarding the incorporation of rehabilitation in PD care.

METHODS

The Task Force, comprised of international multidisciplinary experts in PD and rehabilitation and people directly affected by PD, met virtually to discuss topics such as rehabilitative services, existing therapy guidelines and rehabilitation literature in PD, and gaps and needs. A systematic, interactive, and iterative process was used to develop consensus-based statements on core components of PD rehabilitation and discipline-specific interventions.

RESULTS

The expert-based consensus statement outlines key tenets of rehabilitative care including its multidisciplinary approach and discipline-specific guidance for occupational therapy, physical therapy, speech language pathology/therapy, and psychology/neuropsychology across all PD stages.

CONCLUSIONS

Rehabilitative interventions should be an essential component in the comprehensive treatment of PD, from diagnosis to advanced disease. Greater education and awareness of the benefits of rehabilitative services for people with PD and their care partners, and further evidence-based and scientific study are encouraged.

How COVID-19 will boost remote exercise-based treatment in Parkinson's disease: a narrative review

The lack of physical exercise during the COVID-19 pandemic-related quarantine measures is challenging, especially for patients with Parkinson's disease (PD). Without regular exercise not only patients, but also nursing staff and physicians soon noticed a deterioration of motor and non-motor symptoms. Reduced functional mobility, increased falls, increased frailty, and decreased quality of life were identified as consequences of increased sedentary behavior. This work overviews the current literature on problems of supplying conventional physiotherapy and the potential of telerehabilitation, allied health services, and patient-initiated exercise for PD patients during the COVID-19 period. We discuss recent studies on approaches that can improve remote provision of exercise to patients, including telerehabilitation, motivational tools, apps, exergaming, and virtual reality (VR) exercise. Additionally, we provide a case report about a 69-year-old PD patient who took part in a 12-week guided climbing course for PD patients prior to the pandemic and found a solution to continue her climbing training independently with an outdoor rope ladder. This case can serve as a best practice example for non-instructed, creative, and patient-initiated exercise in the domestic environment in difficult times, as are the current. Overall, many recent studies on telemedicine, telerehabilitation, and patient-initiated exercises have been published, giving rise to optimism that facilitating remote exercise can help PD patients maintain physical mobility and emotional well-being, even in phases such as the COVID-19 pandemic. The pandemic itself may even boost the need to establish comprehensive and easy-to-do telerehabilitation programs.

Distressed doctors: a narrative and historical study of work-related mental discomfort among practising physicians

This article explores the complexity of mental distress among physicians, as portrayed in two literary narratives: John Berger and Jean Mohr's A Fortunate Man: The Story of a Country Doctor (1967) and Pia Dellson's Väggen: En utbränd psykiaters noteringar (2015, 'The Wall: Notes by a Burnt-Out Psychiatrist'). Departing from a historical understanding of medical practice, the article seeks to discuss whether some of the noted similarities and differences in the two narratives could be related to changes appearing over time in the role model of the medical encounter. As the two narratives provide illustrative descriptions of the difficulties experienced by doctors suffering from mental discomfort, they also call for a greater awareness among medical practitioners of the sociological terms of doctoring. Practising a person-centred, rather than patient-centred, care might be part of such awareness and is discussed as a possible protective strategy for physicians at risk of work-related mental distress.

Structured Care and Self-Management Education for Persons with Parkinson's Disease: Why the First Does Not Go without the Second-Systematic Review, Experiences and Implementation Concepts from Sweden and Germany

Integrated care is regarded as a key for care delivery to persons with chronic long-term conditions such as Parkinson’s disease. For persons with Parkinson’s disease, obtaining self-management support is a top priority in the context of integrated care. Self-management is regarded as a crucial competence in chronic diseases since the affected persons and their caregivers inevitably take up the main responsibility when it comes to day-to-day management. Formal self-management education programs with the focus on behavioral skills relevant to the induction and maintenance of behavioral change have been implemented as a standard in many chronic long-term conditions. However, besides the example of the Swedish National Parkinson School, the offers for persons with Parkinson’s disease remain fragmented and limited in availability. Today, no such program is implemented as a nationwide standard in Germany. This paper provides (1) a systematic review on structured self-management education programs specifically designed or adopted for persons with Parkinson’s disease, (2) presents the Swedish National Parkinson School as an example for a successfully implemented nationwide program and (3) presents a concept for the design, evaluation and long-term implementation of a future-orientated self-management education program for persons with Parkinson’s disease in Germany.

Moving towards home-based community-centred integrated care in Parkinson's disease

People living with Parkinson's disease (PwP) experience a wide range of motor and non-motor symptoms associated with increasing complexity of care delivery. A multispecialty approach has been presented as an intuitive solution for tailored and comprehensive care delivery. Nevertheless, past trials of both multidisciplinary or interdisciplinary care models in PD suggested no measurable change to a small benefit in quality of life (QoL) and failed to show economic sustainability. We propose a home-based community-centred integrated care (iCARE-PD) for PwP as a pragmatic solution to harness the potential of existing care resources using an integrated care strategy, enable self-management support and implement technology-enabled care. The iCARE-PD model is based on Freeman's concept of continuity of care and the expanded Chronic Care Model for organization of care strategies. A home-based community-centred integrated care has immediate implications for clinical practice, with potential benefits in rural areas or lower-income countries, by enhancing access to care with optimized costs. There is a need to establish which and how interventions may be used as an instrument of care in each local deployment of the iCARE-PD model. We put forward a multidisciplinary framework to generate the evidence supportive of its implementation as the standard of care in the future and delineate the core strategies to secure the implementation of this care approach across different health care systems to ensure feasibility and economic sustainability. We envision this model becoming a paradigm of personalized care transferable to people with atypical forms of neurodegenerative parkinsonism.

Sharing our story individualized and triadic nurse meetings support couples adjustment to living with deep brain stimulation for Parkinson's disease

Treatment with deep brain stimulation for Parkinson’s disease, leads to a rapid improvement in mobility, which may challenge patients and spouses when adjusting to everyday life. An intervention, developed to support the adjustment to everyday life with DBS, demonstrated that individualized meetings with a specialized nurse was experienced as important and fruitful by both patient and spouses. Purpose: The aim was to gain a deeper understanding of how the meetings contributed to the adjustment process. Method: 38 audio-recorded meetings and six written summaries from eight couples participating in the intervention, were analyzed in a hermeneutic process. Results: The analysis revealed four themes: A relational triad of co-creating personal knowing. Sharing and listening in an atmosphere of trust and openness. Unveiling the couple’s everyday life, coping strategies and expectations. Supporting adjustment through knowing their personal story. Conclusion: The triadic dynamics in the meetings were quite particular. The main focus was the patients’ and spouses’ stories, individually and as a couple. The DBS nurse pursues solutions based on professional and specialized knowledge of Parkinson’s disease and the couple’s everyday life. Thus, the intervention meetings offered tailored, individualized and specialized care in supporting adjustment to DBS for PD both individually and as couples.

Advance care planning in Parkinson's disease: ethical challenges and future directions

Recent discoveries support the principle that palliative care may improve the quality of life of patients with Parkinson's disease and those who care for them. Advance care planning, a component of palliative care, provides a vehicle through which patients, families, and clinicians can collaborate to identify values, goals, and preferences early, as well as throughout the disease trajectory, to facilitate care concordant with patient wishes. While research on this topic is abundant in other life-limiting disorders, particularly in oncology, there is a paucity of data in Parkinson's disease and related neurological disorders. We review and critically evaluate current practices on advance care planning through the analyses of three bioethical challenges pertinent to Parkinson's disease and propose recommendations for each.

A physical therapy decision-making tool for stratifying persons with Parkinson's disease into community exercise classes

Aim: Physical therapy and exercise are considered essential components in the management of Parkinson's disease (PD). Using our retrospective data and years of experience in assigning persons with PD to multilevel group classes we propose a two-part physical therapy decision-making tool consisting of participant and exercise program considerations. Methods: Retrospective medical record review and therapist consensus identified evaluation considerations determined to aide clinical decision making. The ability of these variables (i.e., demographics, clinical characteristics, clinical measures cut-offs) to predict the class assignment decision of PD-specialized physical therapists was evaluated using discriminant function analysis. Results: Therapist-assigned groups differed significantly on all clinical measures (p < 0.001) which provided the categorical data required for discriminant analysis. Using all variables, the discriminant function analysis predicted class assignment of the therapists with 79% agreement. Conclusion: This proposed tool provides a framework that may guide the process for increasing access to multilevel group classes.

How do specialist trainee doctors acquire skills to practice patient-centred care? A qualitative exploration

OBJECTIVES

The importance of patient-centred care (PCC) has been increasingly recognised. However, there is limited work exploring what doctors actually understand by PCC, and how they perceive they acquire PCC skills in the workplace. The objectives of our study were to explore (1) what UK doctors, in specialist training, perceive to be the essential components of PCC, (2) if/how they acquire these skills, (3) any facilitators/barriers for engaging in PCC and (4) views on their PCC training.

DESIGN

Qualitative study using in-depth individual semi-structured interviews with UK specialist trainees. Interview transcripts were thematically analysed.

SETTING AND PARTICIPANTS

Thirty-one specialist trainee doctors, with at least 4 years postgraduate experience, were interviewed. Participants worked in various medical specialities within the Medical Directorate of an acute hospital in the East Midlands of England.

RESULTS

Interview data were transcribed verbatim and categorised into three main themes. The first theme was 'Understanding PCC' where the doctors gave varied perspectives on what they understood by PCC. Although many were able to highlight key components of PCC, there were also some accounts which demonstrated a lack of understanding. The second theme was 'Learning PCC skills: A work in progress'. Learning to be patient-centred was perceived to be an ongoing process. Within this, trainee doctors reported 'on-the-job' learning as the main means of acquiring PCC skills, but they also saw a place for formal training (eg, educational sessions focussing on PCC, role play). 'Delivering PCC: Beyond the physician' referred to the many influences the doctors reported in learning and delivering PCC including patients, the organisation and colleagues. Observing consultants taking a patient-centred approach was cited as an important learning tool.

CONCLUSIONS

Our findings may assist clinical educators in understanding how trainee doctors perceive PCC, and the factors that influence their learning, thereby helping them shape PCC skills training.

Objective measurement in routine care of people with Parkinson's disease improves outcomes

It is common in medicine to titrate therapy according to target ranges of objectively measured parameters. Objective measurement of motor function is available for Parkinson's Disease (PD), making it possible to optimise therapy and clinical outcomes. In this study, an accelerometry based measurement and predefined target ranges were used to assess motor function in a Northern Tasmania PD cohort managed by a Movement Disorder clinic. Approximately 40% (n = 103) of the total PD population participated in this study and motor scores were within target in 22%. In the 78% above target, changes in oral therapy were recommended in 74%, Advanced Therapy in 12% and treatment was contraindicated in 9%. Following changes in oral therapy, there was a further objective measurement and clinical consultation to establish whether scores had reached target range: if so subjects left the study, otherwise further changes of therapy were recommended (unless contraindications were present). Seventy-seven cases completed the study, with 48% achieving target (including 22% at outset), Advanced Therapy recommended in 19% and contraindications preventing any change in therapy in 17%. In the 43% of cases in whom oral therapy was changed, total UPDRS improved significantly (effect size = 8) as did the PDQ39 in cases reaching target. NMS Quest and MOCA scores also improved significantly. This study shows that many people in a representative cohort of PD would benefit from objective assessment and treatment of their PD features against a target.