Multidisciplinary rehabilitation for people with Parkinson's disease: a randomised controlled study

Multidisciplinary care in Parkinson's disease

Parkinson's Disease (PD) is a multifaceted and progressive disorder characterized by a diverse range of motor and non-motor symptoms. The complexity of PD necessitates a multidisciplinary approach to manage both motor symptoms, such as bradykinesia, gait disturbances and falls, and non-motor symptoms, including cognitive dysfunction, sleep disturbances, and mood disorders, which significantly affect patients' quality of life. Pharmacotherapy, particularly dopaminergic replacement therapy, has advanced to alleviate many symptoms. However, these medications can also induce side effects or aggravate symptoms like hallucinations or orthostatic dysfunction, highlighting the need for comprehensive patient management. The optimal care for PD patients involves a team of specialists, including neurologists, physical and occupational therapists, speech-language pathologists, psychologists, and other medical professionals, to address the complex and individualized needs of each patient. Here, we illustrate the necessity of such a multidisciplinary approach in four illustrative PD cases with different disease stages and motor and non-motor complications. The patients were treated in different treatment settings (specialized outpatient clinic, day clinic, inpatient care including neurorehabilitation). The biggest challenge lies in organizing and implementing such comprehensive care effectively across different clinical settings.

Guideline "Parkinson's disease" of the German Society of Neurology (Deutsche Gesellschaft für Neurologie): concepts of care

INTRODUCTION

In 2023, the German Society of Neurology published a new guideline on Parkinson's disease. An important section dealt with PD care concepts, which represent a particularly dynamic field of PD research, including their implementation in clinical practice. Parkinson's disease is the second most common age-associated neurodegenerative disease. Current estimates of the number of cases in the population describe a significant increase in prevalence in Germany by 2030 with higher proportions in rural areas, which also have a lack of sufficient PD care resources.

RECOMMENDATIONS

In comparison with other international guidelines, which have so far mentioned palliative care and Parkinson's nurses in particular, the German S2k guideline expands the recommended concepts of PD care to include PD day clinics, inpatient complex treatment, and PD networks.

CONCLUSION

Concepts of PD care guidelines are necessary because of the complex and rapidly evolving field of PD care provision. If applied appropriately, the potential for optimized care can be exploited and both the patient burden and the economic burden can be reduced. Given that modern care concepts have so far only been applied in a few regions, it is often impossible to generate broad evidence-based data, so that the evaluation of PD care concepts is partly dependent on expert opinion.

Determining the impact of specialized care on health outcomes and health care utilization in Parkinsonism

BACKGROUND

Although care of Parkinsonism (PKM) is assumed to be optimally provided by movement disorder neurologists within an interdisciplinary clinic model, there is a paucity of published data to support this.

OBJECTIVES

To investigate the impact of movement disorder neurologist care of individuals with Parkinsonism (PKM).

METHODS

A retrospective exposure design was adopted using administrative data. Incident PKM individuals were identified in billing claims. A nine-year exposure period to movement disorder neurologist, general neurologist and non-neurologist care was calculated based on the billing codes. Regression models were used to test the association of provider exposure on time to death and long-term care (LTC) admission. Linear models were used to test varying provider exposure and hospital admissions, hospital days and emergency department visits.

RESULTS

1914 incident individuals were identified. There was no difference in PKM mortality, emergency visits, hospital admissions, or hospital days between providers, however exposure to general neurology and non-neurology care was associated with a significantly higher risk of admission to LTC compared to movement disorder neurologist care (HR 1.43; 95% CI 1.09-1.87 for general neurology (p-value = 0.0089); HR 1.61; 95% CI 1.25-2.05 for non-neurology (p-value = 0.0002), respectively.

CONCLUSION

Movement disorder neurologist care is associated with a lower risk of admission to LTC over general neurologist care in individuals with PKM.

Health-related quality of life in Parkinson's disease: systematic review and meta-analysis of EuroQol (EQ-5D) utility scores

INTRODUCTION

Evaluating the Health-related quality of life (HRQoL) of individuals with Parkinson's disease (PD) holds significant importance in clinical and research settings. The EQ-5D is a widely recognized tool for comprehensive measurement of HRQoL using utility values. This study aims to systematically review and synthesize EQ-5D utility values from existing literature on patients with PD and their caregivers.

METHODS

We conducted a systematic search for studies that provided EQ-5D utility scores for patients with PD, using PubMed-Medline, Scopus, and Embase and selected the studies. The selected studies underwent systematic review, including an assessment of their quality. We performed a meta-analysis using a random-effect model and conducted a meta-regression analysis to investigate sources of heterogeneity among the studies.

RESULTS

The search result of 13,417 articles that were reviewed, 130 studies with 33,914 participants were selected for systematic review, and 79 studies were included for meta-analysis. The pooled EQ-5D utility values and visual analog score (VAS) among PD were 62.72% (60.53-64.93, I2 = 99.56%) and 0.60 (0.55-0.65, I2 = 99.81%), respectively. The pooled scores for caregivers' EQ-VAS and EQ-5D utility were 70.10% (63.99-76.20, I2 = 98.25%) and 0.71 (0.61-0.81, I2 = 94.88%), respectively. Disease duration (P < 0.05) showed a negative correlation with EQ-5D utility values on meta-regression.

CONCLUSION

The pooled utility values of PD and their caregivers help to understand their HRQoL and aid in conducting health economics research. The negative association between disease duration and utility values highlights the evolving nature of HRQoL challenges, suggesting the need for appropriate long-term disease management.

Specialized Allied Health Care for Parkinson's Disease: State of the Art and Future Directions

People with Parkinson's disease (PD) experience a range of progressive motor and non-motor symptoms, that negatively affect their daily functioning, social participation and quality of life. Allied health therapies have emerged as an effective treatment approach-complementary to pharmacological and neurosurgical treatments-which reduces the impact of PD in daily life. In this article, we propose criteria for what constitutes specialized allied health care for PD, and we review allied health research in PD in terms of meeting these criteria and its outcomes for monodisciplinary approaches as well as multi- or interdisciplinary allied health interventions. We focus on the three most studied allied health disciplines in PD: physical therapy, occupational therapy and speech-language therapy. Overall, the available evidence underscores the importance and potential benefits of specialized allied health care for people with PD. Our proposed criteria and recommendations for future research might help in further delineating specialized allied health care.

A comparison of the effects of occupation-based interventions with and without responsibility feedback and conventional interventions on participation in people with idiopathic Parkinson's disease: study protocol for a randomized controlled trial

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder with debilitating motor and non-motor symptoms which affect participation in meaningful occupations. Occupation-based interventions can improve participation in people with PD. Evidence for incorporating structured and intensive occupational therapy by considering the concept of responsibility is lacking for this population. This trial will compare the effects of occupation-based interventions with and without responsibility feedback and conventional interventions on participation in people with idiopathic PD.

METHODS

A total of 45 people with PD, between 35 and 85 years old and Hoehn and Yahr stages between I to III, will be recruited from movement disorder centers for this three-armed study. Participants will be randomized into three groups (occupation-based interventions with responsibility feedback, occupation-based interventions without responsibility feedback, and conventional interventions). All participants will receive intervention for 24 sessions during a period of 12 weeks (2 sessions per week). The primary outcome measure will be participation satisfaction. Participation frequency and restriction, self-perceived performance, performance satisfaction, motivation, volition, sense of agency, responsibility, physical activity, community integration, activities of daily living (ADL), instrumental ADL, upper extremity function, balance, fatigue, and quality of life will be measured as secondary outcome measures. All outcomes will be measured at baseline, session 9, session 17, post-intervention (week 13), and follow-up (week 25).

DISCUSSION

This home-based high-intensity, structured, client-centered, and occupation-based intervention will be conducted by utilizing the concept of responsibility. This proposed trial may result in enhanced participation that would benefit other motor and non-motor symptoms in people living with PD. Findings from this proposed study are expected to expand the knowledge of clinicians and help them in evidence-based decision-making processes.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20140304016830N13. Registered on August 19, 2022.

Occupational performance skills in Parkinson's disease: relationship with health-related quality of life and caregiver burden

INTRODUCTION

The progression of Parkinson's disease (PD) results in a loss of ability to performance activities of daily living and health-related quality of life. The objectives of this study were to establish the relations between occupational performance skills and health-related quality of life, and the degree of caregiver burden in PD patients.

PATIENTS AND METHODS

Forty-nine patients at different stages of PD according to the Hoehn and Yahr scale participated in the study. Patients were assessed using the Parkinson's Disease Questionnaire (PDQ-39), the EuroQoL (EQ-5D), the Assessment of Motor and Process Skills (AMPS), and the Zarit Caregiver Burden Interview (ZCBI).

RESULTS

Strong correlations were found between the motor skills section of the AMPS scale and the PDQ-39 (r = -0.76; p = 0.001), and the EQ-5D questionnaires (r = 0.72; p = 0.001), while moderate correlations were found with the process skills. AMPS process skills were moderately correlated with mobility and activities of daily living. The ZCBI was only weakly correlated with the AMPS motor skills (r = -0.34; p = 0.02).

CONCLUSION

Declining scores on the AMPS scale are closely related to the loss of health-related quality of life in PD patients, and, to a lesser extent, with the degree of caregiver burden.

Efficacy of non-pharmacological interventions for depression in individuals with Parkinson's disease: A systematic review and network meta-analysis

BACKGROUND

Depression in Parkinson's disease (PD) is a major health concern worldwide. Recently, an increasing number of non-pharmacological interventions have been used in PD to alleviate depressive symptoms. However, it is uncertain which intervention is the best, and related evidence is limited. This network meta-analysis was performed to compare and rank non-pharmacological interventions for PD and analyze their effects on depression to provide evidence for clinicians to choose appropriate non-pharmacological management options.

METHODS

The PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from inception to April 7, 2022. Two authors screened all studies, extracted the data, and evaluated the methodological quality. STATA software version 16.0 was used to conduct the network meta-analysis.

RESULTS

Our network meta-analysis included 62 studies involving 3,050 participants and 35 non-pharmacological interventions. Although most non-pharmacological interventions showed non-significant effects, the surface under the cumulative ranking curve (SUCRA) values indicated that the best non-pharmacological intervention for depression was dance (82.3%), followed by LSVT-BIG therapy (77.4%), and CBT (73.6%).

CONCLUSION

Dance can be considered as an effective therapy for improving depression in patients with PD. In the future, more strictly designed trials are needed to verify the conclusions of this network meta-analysis.

Exploring the feasibility of technological visuo-cognitive training in Parkinson's: Study protocol for a pilot randomised controlled trial

Visual and cognitive dysfunction are common in Parkinson's disease and relate to balance and gait impairment, as well as increased falls risk and reduced quality of life. Vision and cognition are interrelated (termed visuo-cognition) which makes intervention complex in people with Parkinson's (PwP). Non-pharmacological interventions for visuo-cognitive deficits are possible with modern technology, such as combined mobile applications and stroboscopic glasses, but evidence for their effectiveness in PwP is lacking. We aim to investigate whether technological visuo-cognitive training (TVT) can improve visuo-cognitive function in PwP. We will use a parallel group randomised controlled trial to evaluate the feasibility and acceptability of TVT versus standard care in PwP. Forty PwP who meet our inclusion criteria will be randomly assigned to one of two visuo-cognitive training interventions. Both interventions will be carried out by a qualified physiotherapist in participants own homes (1-hour sessions, twice a week, for 4 weeks). Outcome measures will be assessed on anti-parkinsonian medication at baseline and at the end of the 4-week intervention. Feasibility of the TVT intervention will be assessed in relation to safety and acceptability of the technological intervention, compliance and adherence to the intervention and usability of equipment in participants homes. Additionally, semi structured interviews will be conducted to explore participants' experience of the technology. Exploratory efficacy outcomes will include change in visual attention measured using the Trail Making Test as well as changes in balance, gait, quality of life, fear of falling and levels of activity. This pilot study will focus on the feasibility and acceptability of TVT in PwP and provide preliminary data to support the design of a larger, multi-centre randomised controlled trial. This trial is registered at isrctn.com (ISRCTN46164906).

The Role of Parkinson Nurses for Personalizing Care in Parkinson’s Disease: A Systematic Review and Meta-Analysis

Background: Quality of life (QoL) of persons with Parkinson’s disease (PD) is diminished by (non-)motor symptoms, that require personalized care. Parkinson Nurses (PN) may be pivotal promoting tailored care offerings. This systematic review and meta-analysis investigates PD care models and aims at furnishing current concepts of PN to offer personalized care. Objective: The purpose of this study is to identify the various roles and functions that PN may hold for personalized PD care. Methods: We performed a systematic literature review, utilizing: PubMed, Web of Science, The Cochrane Library, and PsycINFO. The review qualitatively evaluated articles, which described personalized care models involving PNs and was guided by the personalized care management model. A meta-analysis compared patient-reported QoL (quantified using the 39-item Parkinson’s Disease Questionnaire) between personalized care interventions involving PN versus standard care with. Results: Twenty-seven publications were identified, including six randomized, controlled trials ascertaining with health related QoL (n = 1830 PwPs). The qualitative evaluation revealed that PN contribute to all aspects of personalized care. The meta-analysis showed no improved QoL in personalized care models compared to standard care, thought a great heterogeneity among study design and interventions was outlined (Standardized Mean Difference = –0.8935; 95% Confidence Interval, –2.1177 to 0.3307; z = –1.43, p = 0.1526). Conclusion: PN fulfil important functions in personalized PD care. For the future, a clear role definition will be necessary to adjust training for PN across healthcare systems and care settings but especially to realize their full potential for PD care.

Quality of life predicts rehabilitation prognosis in Parkinson's disease patients: Factors influence rehabilitation prognosis: Factors influence rehabilitation prognosis

BACKGROUND

Rehabilitation has been reported to improve the quality of life (QoL) of patients with Parkinson's disease (PD). Nevertheless, not all patients are satisfied with rehabilitation outcomes and could achieve a significant improvement in QoL.

OBJECTIVE

To detect possible predictors of QoL improvement in patients with PD after rehabilitation.

METHODS

A total of 86 PD patients were included and followed up for 3 months with a 39-item Parkinson's Disease Questionnaire summary index (PDQ-39 SI) as the primary endpoint. All patients received 2 weeks of multidisciplinary intensive rehabilitation treatment (MIRT). Changes in patients' QoL were assessed using the PDQ-39 at baseline and at the 3-month follow-up. The reliable change index (RCI) was adapted to determine the individual QoL outcome. The predictors of QoL outcome were detected using logistic regression analysis.

RESULTS

After a 3-month follow-up, PDQ-39 SI decreased significantly from 22.95 ± 9.75 to 18.73 ± 10.32 (P < 0.001). Scores for QoL improved (RCI>10.9) after rehabilitation for 18.6% of the patients, and 74.4% of patients reported an unchanged QoL (-10.9≤RCI≤10.9), while 7.0% of patients reported a worsening of QoL (RCI<-10.9). Among the baseline parameters, the PDQ-39 SI was a baseline predictor for changes in QoL in the logistic regression model (OR: 1.15, CI: 1.07-1.24, P < 0.001).

CONCLUSIONS

MIRT could improve QoL for some patients with PD, and PDQ-39 score at baseline is the most important predictor for QoL improvements after rehabilitation for this patients.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Optimal Treatment of Depression and Anxiety in Parkinson's Disease

Depression and anxiety are highly prevalent and have major adverse effects on function and quality of life in Parkinson's disease (PD). Optimal management requires that motor symptoms and psychiatric symptoms be simultaneously addressed. While there is fairly robust evidence for the treatment of motor symptoms, there are no completed randomized controlled trials to guide pharmacological treatment of anxiety in PD and no nonpharmacologic interventions have proven efficacious. Several high-quality trials for depression in PD suggest a number of antidepressants and cognitive behavioral therapy may help, but there is no data on rates of recurrence, comparative efficacy, or augmentation strategies. In order to address the gaps in knowledge, the authors provide a summary of the current evidence for treating depression and anxiety in PD and offer an algorithm that extends beyond the current literature based on clinical experience working in a multidisciplinary specialty center.

Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials

We performed a meta-analysis to synthesize evidence on the efficacy and safety of physical exercise as an add-on therapeutic intervention for quality of life (QoL), depressive symptoms and cognition across six chronic brain disorders: Alzheimer's disease, Huntington's disease, multiple sclerosis, Parkinson's disease, schizophrenia and unipolar depression. 122 studies ( = k) (n = 7231) were included. Exercise was superior to treatment as usual in improving QoL (k = 64, n = 4334, ES = 0.40, p < 0.0001), depressive symptoms (k = 60, n = 2909, ES = 0.78, p < 0.0001), the cognitive domains attention and working memory (k = 21, n = 1313, ES = 0.24, p < 0.009), executive functioning (k = 14, n = 977, ES = 0.15, p = 0.013), memory (k = 12, n = 994, ES = 0.12, p = 0.038) and psychomotor speed (k = 16, n = 896, ES = 0.23, p = 0.003). Meta-regression showed a dose-response effect for exercise time (min/week) on depressive symptoms (β = 0.007, p = 0.012). 69% of the studies that reported on safety, found no complications. Exercise is an efficacious and safe add-on therapeutic intervention showing a medium-sized effect on QoL and a large effect on mood in patients with chronic brain disorders, with a positive dose-response correlation. Exercise also improved several cognitive domains with small but significant effects.

Efficacy of Occupational Therapy Interventions on Quality of Life in Patients with Parkinson's Disease: A Systematic Review and Meta-Analysis

Objective

To review studies assessing the efficacy of occupational therapy interventions on quality of life in patients with Parkinson's disease.

Method

We followed the international guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Databases (PubMed, Physiotherapy Evidence Database, OTsekeer, Scopus, Cinhal, and Web of Science) were searched to identify randomized controlled trials of occupational therapy interventions in patients with Parkinson's disease up to 2019 and with no restriction on language. The primary outcome of the meta-analysis was the evaluation of quality of life following occupational therapy interventions. Because of the heterogeneity of the studies, we examined the data by using a random effect model.

Results

We identified 15 randomized controlled trials that met the inclusion criteria, and 4 of these were included in the meta-analysis. Studies with a follow-up of 2 to 3 months showed that occupational therapy interventions significantly improved the quality of life in patients with Parkinson's disease, with a mean difference of -2.08 (95% confidence interval, -2.52 to -1.64; P < 0.00001). Studies reporting a longer follow-up (6-12 months) also showed that occupational therapy interventions improved the quality of life, with a mean difference of -2.56 (95% confidence interval, -3.52 to -1.61; P < 0.00001).

Conclusion

Different occupational therapy interventions may be effective in improving the quality of life in patients with Parkinson's disease. However, because of the limited number of studies available, the strength of the evidence should be considered moderate.

Recommendations for the Organization of Multidisciplinary Clinical Care Teams in Parkinson's Disease

BACKGROUND

Optimal management in expert centers for Parkinson's disease (PD) usually involves pharmacological and non-pharmacological interventions, delivered by a multidisciplinary approach. However, there is no guideline specifying how this model should be organized. Consequently, the nature of multidisciplinary care varies widely.

OBJECTIVE

To optimize care delivery, we aimed to provide recommendations for the organization of multidisciplinary care in PD.

METHODS

Twenty expert centers in the field of multidisciplinary PD care participated. Their leading neurologists completed a survey covering eight themes: elements for optimal multidisciplinary care; team members; role of patients and care partners; team coordination; team meetings; inpatient versus outpatient care; telehealth; and challenges towards multidisciplinary care. During a consensus meeting, outcomes were incorporated into concept recommendations that were reviewed by each center's multidisciplinary team. Three patient organizations rated the recommendations according to patient priorities. Based on this feedback, a final set of recommendations (essential elements for delivery of multidisciplinary care) and considerations (desirable elements) was developed.

RESULTS

We developed 30 recommendations and 10 considerations. The patient organizations rated the following recommendations as most important: care is organized in a patient-centered way; every newly diagnosed patient has access to a core multidisciplinary team; and each team has a coordinator. A checklist was created to further facilitate its implementation.

CONCLUSION

We provide a practical tool to improve multidisciplinary care for persons with PD at the organizational level. Future studies should focus on implementing these recommendations in clinical practice, evaluating their potential applicability and effectiveness, and comparing alternative models of PD care.

Geriatric models of care for neurodegenerative disorders

New models of care seek to reorganize healthcare to meet the challenges of a growing number of persons with chronic conditions, to optimize the use of the available workforce, and to improve the quality of care. Increasingly, these models also seek to organize care in a manner that addresses cost and efficiency in addition to quality of care. This chapter first revisits the history of chronic care models and then provides a description of successful and sustainable examples of integrated, multidisciplinary approaches for persons with dementia, persons with Parkinson's disease, and the frail elderly. We focus on models for neurodegenerative diseases and draw from the perspectives of research, clinical practice, and informal caregiving. Although focused on neurodegenerative disease, the principles of these approaches reflect the hallmarks of good primary, geriatric, and collaborative care. Many of the current models of care emanate from a medical approach led by physicians and other professional providers within the formal healthcare setting. Innovative approaches, however, now seek to incorporate these medical models within social and community services. We conclude this chapter by describing several international examples of community-based efforts that have been implemented to improve the care and lives of patients with dementia and their informal caregivers, which is at present one of the top priorities in many countries.

Multidisciplinary Care to Optimize Functional Mobility in Parkinson Disease

This review elaborates on multidisciplinary care for persons living with Parkinson disease by using gait and balance impairments as an example of a treatable target that typically necessitates an integrated approach by a range of different and complementary professional disciplines. Using the International Classification of Functioning, Disability, and Health model as a framework, the authors discuss the assessment and multidisciplinary management of reduced functional mobility due to gait and balance impairments. By doing so, they highlight the complex interplay between motor and nonmotor symptoms, and their influence on rehabilitation. They outline how multidisciplinary care for Parkinson disease can be organized.

Ancillary Service Utilization and Impact in Huntington's Disease

BACKGROUND

Prior Huntington's disease (HD) studies suggest ancillary services improve motor symptoms, cognition, mood, and quality of life but frequency of use and clinicalcharacteristics are unclear.

OBJECTIVE

Describe ancillary service utilization in a cohort of individuals with HD and determine which participant characteristics are associated with ancillary service utilization.

METHODS

Retrospective cross-sectional analysis of Enroll-HD database. Participants were grouped by therapy: physical and/or occupational (PT/OT), psychotherapy and/or counseling (PC), speech and/or swallowing (ST). We performed bivariate comparisons analysis of demographic and disease characteristics between those with/without each therapy and to analyze one-year mean change in assessment scores.

RESULTS

Of 4751 participants, 1537 (32.35%) utilized therapies (11.82% PT/OT, 5.33% PC, 3.01% ST, 1.98% all three, 10.21% two therapies). PT/OT participants had worse motor and functional scores: mean UHDRS motor score (41.17 vs. 38.05, p = 0.002), median total functional capacity score (TFC) (8.00 vs. 9.00, p < 0.001). PC participants had worse mood but better cognitive and functional scores: median depression score (7.00 vs. 2.00, p < 0.001), median MMSE (28.00 vs. 26.00, p < 0.001), median TFC (10.00 vs. 8.00, p < 0.001). ST participants had more dysarthria, and worse cognitive and functional scores: dysarthria (32.2% vs. 20.1% p < 0.001), mean correct Symbol Digit Modality Test (16.79 vs. 23.27, p < 0.001), median TFC (6.00 vs. 9.00, p < 0.001). Over one year, PC participants' depression scores improved compared to untreated (- 1.24 vs. - 0.11, p = 0.040). ST participants' depression scores worsened (1.14 vs. - 0.23, p = 0.044). Mean change in TFC was not significant for any therapies.

CONCLUSIONS

Only 32% of Enroll-HD site participants received ancillary services. Use correlated with expected clinical characteristics, though impact of use remains unclear.

Clinical effectiveness and cost-effectiveness of physiotherapy and occupational therapy versus no therapy in mild to moderate Parkinson's disease: a large pragmatic randomised controlled trial (PD REHAB)

BACKGROUND

Cochrane reviews of physiotherapy (PT) and occupational therapy (OT) for Parkinson's disease found insufficient evidence of effectiveness, but previous trials were methodologically flawed with small sample size and short-term follow-up.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of individualised PT and OT in Parkinson's disease.

DESIGN

Large pragmatic randomised controlled trial.

SETTING

Thirty-eight neurology and geriatric medicine outpatient clinics in the UK.

PARTICIPANTS

Seven hundred and sixty-two patients with mild to moderate Parkinson's disease reporting limitations in activities of daily living (ADL).

INTERVENTION

Patients were randomised online to either both PT and OT NHS services (n = 381) or no therapy (n = 381). Therapy incorporated a patient-centred approach with individual assessment and goal setting.

MAIN OUTCOME MEASURES

The primary outcome was instrumental ADL measured by the patient-completed Nottingham Extended Activities of Daily Living (NEADL) scale at 3 months after randomisation. Secondary outcomes were health-related quality of life [Parkinson's Disease Questionnaire-39 (PDQ-39); European Quality of Life-5 Dimensions (EQ-5D)], adverse events, resource use and carer quality of life (Short Form questionnaire-12 items). Outcomes were assessed before randomisation and at 3, 9 and 15 months after randomisation.

RESULTS

Data from 92% of the participants in each group were available at the primary time point of 3 months, but there was no difference in NEADL total score [difference 0.5 points, 95% confidence interval (CI) -0.7 to 1.7; p = 0.4] or PDQ-39 summary index (0.007 points, 95% CI -1.5 to 1.5; p = 1.0) between groups. The EQ-5D quotient was of borderline significance in favour of therapy (-0.03, 95% CI -0.07 to -0.002; p = 0.04). Contact time with therapists was for a median of four visits of 58 minutes each over 8 weeks (mean dose 232 minutes). Repeated measures analysis including all time points showed no difference in NEADL total score, but PDQ-39 summary index (curves diverging at 1.6 points per annum, 95% CI 0.47 to 2.62; p = 0.005) and EQ-5D quotient (0.02, 95% CI 0.00007 to 0.03; p = 0.04) showed significant but small differences in favour of the therapy arm. Cost-effective analysis showed that therapy was associated with a slight but not significant gain in quality-adjusted life-years (0.027, 95% CI -0.010 to 0.065) at a small incremental cost (£164, 95% CI -£141 to £468), resulting in an incremental cost-effectiveness ratio of under £4000 (£3493, 95% -£169,371 to £176,358). There was no difference in adverse events or serious adverse events.

CONCLUSIONS

NHS PT and OT did not produce immediate or long-term clinically meaningful improvements in ADL or quality of life in patients with mild to moderate Parkinson's disease. This evidence does not support the use of low-dose, patient-centred, goal-directed PT and OT in patients in the early stages of Parkinson's disease. Future research should include the development and testing of more structured and intensive PT and OT programmes in patients with all stages of Parkinson's disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17452402.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 63. See the NIHR Journals Library website for further project information. The Birmingham Clinical Trials Unit, University of Birmingham, received support from the UK Department of Health up to March 2012. Catherine Sackley was supported by a NIHR senior investigator award, Collaboration for Leadership in Applied Health Research and Care East of England and West Midlands Strategic Health Authority Clinical Academic Training award.

Patient-centered integrated healthcare improves quality of life in Parkinson's disease patients: a randomized controlled trial

INTRODUCTION

Improving quality of life (QoL) is a key issue when dealing with Parkinson's disease (PD). Integrative care shows potential to achieve improvements in QoL. Here, we analyzed whether a community-based, open-label, integrated approach improves QoL in PD patients.

METHODS

PD patients were screened for eligibility and evaluated by a university-based PD specialist, a PD nurse, and a general neurologist at a local practice. Patients were randomly assigned to a control group (CG), receiving standard German neurological treatment including a baseline assessment and follow-up visit at 6 months, or an interventional group (IG) who received an individually tailored therapy plan and additional home visits. Patients and investigators were not blinded for either intervention. Primary outcome analysis compared the differential change of PDQ-39 from baseline to 6-month follow-up between CG and IG. Between-group changes in mood, motor/non-motor functioning, and cognition were secondary outcomes.

RESULTS

300 patients were included and randomized equally to IG and CG. 132 IG and 125 CG patients had a valid PDQ-39 at follow-up and qualified for the modified ITT analysis. PDQ-39 improved more in IG compared to CG [2.2 points (95% CI - 4.4 to 0.1); p = 0.044]. Likewise, change scores between IG and CG favored IG for UPDRS III (p < 0.001, mean change 3.3, 95% CI - 4.9 to - 1.7) and PD-NMS (p < 0.001, mean change 11.3, 95% CI - 17.1 to - 5.5).

CONCLUSIONS

Data show that an integrated approach, compared to regular PD care, improves QoL as well as motor and nonmotor PD symptoms over 6 months. Future studies need to address the cost-benefit ratio and whether positive effects can be maintained beyond intervention.

Health-related quality of life in people with Parkinson's disease receiving comprehensive care

Objectives The aim of the present study was to quantify the baseline variation in health-related quality of life (HRQOL) between individuals with Parkinson's disease (PD) referred to a comprehensive care program and those attending standard neurological services. Methods Participants included individuals with PD receiving conventional care from neurologists in private practice and individuals referred to a comprehensive inter-professional team hospital out-patient service. The Parkinson's Disease Questionnaire-39 (PDQ-39) and the EuroQoL (EQ-5D-3L) were used to quantify HRQOL. Results Participants referred to an inter-professional service were more likely to have poorer indices on PD-specific measures but not for generic HRQOL compared with individuals receiving standard neurological services. After adjusting for age, gender, disease severity and duration, people referred to a comprehensive care program were more likely to have a higher score for the PDQ-39 summary index (PDQ-39 SI; mean±s.d. 27.2±11.0; 95% confidence interval (CI) 25.5, 28.9) compared with individuals receiving standard neurological services (PDQ-39 SI mean 0.2±12.8; 95% CI 18.0, 22.4). Conclusions Compared with those attending standard neurological out-patient clinics, individuals referred to an inter-professional PD program are more likely to have advanced disease and poorer HRQOL. This observation has implications for the way in which people with PD are recruited for future clinical trials, because uneven recruitment from different sources may be a potential source of bias. What is known about the topic? Given that PD is associated with a complex array of motor and non-motor symptoms, an inter-professional team approach to service provision is argued to be optimal for individuals living with this debilitating condition. What does this paper add? This paper has shown that individuals referred to an inter-professional service are more likely to have advanced disease and complex care needs. Compared with those referred to neurologist private clinics, those referred to an inter-professional clinic had less functional independence and lower PD-specific HRQOL when first assessed, even after controlling for disease severity. What are the implications for practitioners? When recruiting for future trials to examine the efficacy of multidisciplinary care programs in people with PD, it is important to take into account whether these individuals have been referred to an inter-professional service. There may be a potential source of bias if participants were recruited predominantly from such services.

Physical Therapy Versus a General Exercise Programme in Patients with Hoehn Yahr Stage II Parkinson's Disease: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Several studies suggest that general exercise (GE) and physical therapy programmes (PT) improve the outcomes of Parkinson's disease (PD) patients; however, the available data do not allow a determination of which treatment is more effective. Our study aims to compare the effects of physiotherapy and general exercise in Parkinson's disease.

METHODS

Design and setting: Randomized controlled trial -general hospital outpatient clinic. The participants were patients with Hoehn Yahr stage II PD. Two randomized groups: one receiving PT and one receiving GE. The outcome measures were the FIM, Hamilton Rating Scale, TUG test, and UPDRS.

RESULTS

FIM median scores improved by 3 points in the PT group after treatment, and the improvements were maintained at follow-up. The GE FIM median scores were unchanged after treatment and were reduced by 1 point at follow-up (p < 0.05). The TUG test time was reduced in the PT group but increased in the GE group with a 3-second difference between groups at follow-up, suggesting improved functional mobility after specific physiotherapy (p < 0.05). The UPDRS median score change from baseline was significantly different between the two groups at the end of treatment (6.5 points) and at follow-up (11 points), with a benefit for the physiotherapy group.

CONCLUSIONS

Physiotherapy seems to be more effective than a generic exercise programme in patients with Hoehn Yahr stage II PD.

Caregiver Burden in Parkinson Disease: A Critical Review of Recent Literature

Burden is a negative psychological state induced in caregivers by the demands of providing care to a person with an illness or a disability. Managing caregiver burden in Parkinson disease (PD) is significant because informal caregivers make a substantial contribution to the well-being of persons with PD, incurring financial, social, and personal losses. Failure to recognize and manage caregiver burden may lead to burnout and premature institutionalization of the person with PD. We conducted a comprehensive literature review to identify and summarize factors that may amplify burden, including motor and nonmotor symptoms of PD, caregiver psychiatric symptoms, and caregiver coping style. We review instruments designed to sample the construct of burden among caregivers and evaluate interventions that may reduce burden, either by directly targeting caregivers or by treating PD symptoms associated with burden. We aim to provide a concise synopsis of these issues for the clinician or researcher working with this population in order to facilitate recognition of caregiver burden, provide accurate assessment, administer appropriate interventions, and stimulate further research in this area.

Physiotherapy for Parkinson's Disease in Sweden: Provision, Expertise, and Multi-professional Collaborations

Background

Evidence for the positive effects of physiotherapy for persons with Parkinson's disease (PwPD) is rapidly increasing. However, little is known about the provision of physiotherapy for PwPD in everyday practice. The objective of this study was to gain insight into the nature of physiotherapeutic care for PwPD in hospitals, primary care units, and community services in Sweden.

Methods

A web-based survey was sent out to 2956 members of the Swedish Association of Physiotherapists, including questions about treatment, measurement tools, multi-professional collaborations, adherence to physiotherapy guidelines, professional expertise, and needs for gaining expertise regarding PwPD.

Results

Of the 1189 physiotherapists who completed the survey, 705 were treating 1 or more PwPD per month in hospitals (21%), in primary care units (37%), and in the community (42%). Physiotherapy frequently targeted a wide range of musculoskeletal and mobility impairments; however, freezing of gait and pain were less frequently treated. Measurement tools recommended for PwPD were infrequently used, and there was a preference for single-item questions/tools compared with multi-item instruments. Collaboration with other health care professionals for the rehabilitation of PwPD was rare and was more evident in hospitals than in primary care units and the community. Adherence to physiotherapy guidelines was poor, and most respondents reported that they treated too few PwPD to retain their expertise and they perceived a need to increase their knowledge and skills about physiotherapy for PwPD.

Conclusion

The current findings emphasize the need to strengthen expertise regarding the assessment and treatment of PwPD among physiotherapists in Sweden and to apply strategies endorsing multi-professional collaboration for PD rehabilitation.

Expanding role of molecular chaperones in regulating α-synuclein misfolding; implications in Parkinson's disease

Protein misfolding under stressful environmental conditions cause several cellular problems owing to the disturbed cellular protein homeostasis, which may further lead to neurological disorders like Parkinson's disease (PD), Alzheimer's disease (AD), Amyloid lateral sclerosis and Huntington disease (HD). The presence of cellular defense mechanisms like molecular chaperones and proteasomal degradation systems prevent protein misfolding and aggregation. Molecular chaperones plays primary role in preventing protein misfolding by mediating proper native folding, unfolding and refolding of the polypeptides along with vast number of cellular functions. In past few years, the understanding of molecular chaperone mechanisms has been expanded enormously although implementation to prevent protein aggregation diseases is still deficient. We in this review evaluated major classes of molecular chaperones and their mechanisms relevant for preventing protein aggregation, specific case of α-synuclein aggregation. We also evaluate the molecular chaperone function as a novel therapeutic approach and the chaperone inhibitors or activators as small molecular drug targets.

The role and structure of the multidisciplinary team in the management of advanced Parkinson's disease with a focus on the use of levodopa-carbidopa intestinal gel

A multidisciplinary team (MDT) approach is increasingly recommended in Parkinson’s disease (PD) treatment guidelines, but no standard of care exists for such an approach, and the guidelines do not provide clarification on how it should be implemented. This paper reviews evidence of MDT interventions in people with PD and provides expert clinical perspectives for an MDT approach, with a focus on advanced PD and levodopa–carbidopa intestinal gel (carbidopa–levodopa enteral suspension in the USA). The key recommendations are to enable the best possible treatment of people with PD locally by facilitating a close structured collaboration of different health care professionals working in a fixed network structure; to refer people with PD to established MDT centers in a timely manner; to establish regular meetings for the MDT enabling interdisciplinary exchange and learning; to optimize individual treatment and carefully evaluate available treatment options; to ensure treatment decisions are agreed jointly between people with PD, their caregivers, family, and health care professional; and to include specialists outside of neurology from adjuvant medical departments as necessary when implementing advanced therapies.

Randomised Controlled Trials: Part 1, Design

Occupational therapists need to be able to evaluate the profession's interventions critically: to stop the ineffective, to reduce the hazardous and to promote the effective. Randomised controlled trials are a research tool for testing the efficacy of interventions with small to moderate effects. This review aims to cover the issues to be considered when designing a randomised controlled trial of complex interventions, such as occupational therapy.

Pisa syndrome in Parkinson's disease: An integrated approach from pathophysiology to management

Pisa syndrome was first described in 1972 in patients treated with neuroleptics. Since 2003, when it was first reported in patients with Parkinson's disease (PD), Pisa syndrome has progressively drawn the attention of clinicians and researchers. Although emerging evidence has partially clarified its prevalence and pathophysiology, the current debate revolves around diagnostic criteria and assessment and the effectiveness of pharmacological, surgical, and rehabilitative approaches. Contrary to initial thought, Pisa syndrome is common among PD patients, with an estimated prevalence of 8.8% according to a large survey. Furthermore, it is associated with the following specific patient features: more severe motor phenotype, ongoing combined pharmacological treatment with levodopa and dopamine agonists, gait disorders, and such comorbidities as osteoporosis and arthrosis. The present literature on treatment outcomes is scant, and the uneven effectiveness of specific treatments has produced conflicting results. This might be because of the limited knowledge of Pisa syndrome pathophysiology and its variable clinical presentation, which further complicates designing randomized clinical trials on this condition. However, because some forms of Pisa syndrome are potentially reversible, there is growing consensus on the importance of its early recognition and the importance of pharmacological adjustment and rehabilitation. © 2016 International Parkinson and Movement Disorder Society.

Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson's disease

Objective: To use cost-consequences analysis to evaluate rehabilitation, and to discuss some practical limitations.

Design: Case study of a cost-consequences analysis.

Setting: Day hospital.

Subjects: People with Parkinson's disease without major cognitive loss, and their carers.

Intervention: A programme of multidisciplinary rehabilitation, delivered for one day per week over six weeks, and including 2 h of individual therapy (physical, occupational, speech and language, specialist nurse) and group activities on each occasion.

Main measures: Costs: direct and overhead costs of treatment; participant travel. Consequences: patient outcomes (mobility, speech and language, disability, psychological well-being, health-related quality of life); carer outcomes (psychological well-being, health-related quality of life, strain); social service utilization; satisfaction.

Results: In this example the main costs were facility's overheads and hospital-provided transport. The consequences of the intervention were improved immediate outcomes for patients that diminished over four months, discovery of unmet social services need, high satisfaction. No benefits for carers were observed.

Conclusion: A cost-consequences analysis provides a clear descriptive summary for decision-makers that is easier to interpret than cost-effectiveness, cost-utility and cost-benefit analysis. It is a useful technique in rehabilitation research where multiple outcomes and several perspectives (health service, patient, carer) are relevant. However limitations remain: it is difficult to capture all consequences because of data deficiencies and long-term effects; evaluations of individual interventions are partial and do not guarantee economic rationality; local studies may not be generalizable; fixed protocols impede the evaluation of alternative service configurations.

Evaluation of physical therapy in parkinsonian patients with freezing of gait: a pilot study

Objective: Freezing of gait is a frequently disabling symptom in Parkinson's disease, poorly responding to dopaminergic treatment. We investigated the short-term effectiveness of a rehabilitation protocol in parkinsonian patients with freezing of gait.

Design: Prospective, uncontrolled pilot study with open label design.

Setting: Outpatient service for rehabilitation of neurological disorders.

Subjects: Twelve patients (8 male, 4 female; aged 59-78 years; Hoehn-Yahr stage: 2-3; mean disease duration: 14.29±SD 4.1 years).

Interventions: Patients attended three (45 min) sessions every week, over a six-week period, of physical therapy focused to improve balance, postural control and walking, and to learn new strategies for overcoming freezing of gait.

Main outcome measures: Patients were evaluated before (T0), at the end (T1), and one month after (T2) rehabilitation by means of clinical rating scales (Unified Parkinson Disease Rating Scale-Motor Section; Freezing of Gait Questionnaire; Parkinson Disease Quality of Life Score) and gait parameters (number of strides, stride length and velocity) during a standardized walking test.

Results: The scores of Freezing of Gait Questionnaire and of Parkinson Disease Quality of Life Questionnaire (but not of the Unified Parkinson Disease Rating Scale-Motor Section) were significantly improved after treatment (T1). Gait parameters were significantly improved at T1 and T2.

Conclusions: We showed the potential short-term efficacy of a rehabilitative approach to freezing of gait in Parkinson's disease. The positive outcome was documented by clinical rating scales and objective gait evaluation. The rapid reversibility of the clinical benefit suggests that further studies are needed to better define the optimal frequency and duration of treatment.

Effects of an intensive rehabilitation programme on patients with Huntington's disease: a pilot study

Objective: To investigate the effects of an intensive, inpatient rehabilitation programme on individuals affected by Huntington's disease.

Design: A pilot study. Within-subjects design.

Setting: Inpatient rehabilitation home of the Italian welfare system.

Subjects: Forty patients, early and middle stage of the disease, were recruited to an intensive, inpatient rehabilitation protocol.

Interventions: The treatment programme included respiratory exercises and speech therapy, physical and occupational therapy and cognitive rehabilitation exercises. The programme involved three-week admission periods of intensive treatment that could be repeated three times a year.

Main measures: A standard clinical assessment was performed at the beginning of each admission using the Zung Depression Scale, Mini-Mental State Examination (MMSE), Barthel Index, Tinetti Scale and Physical Performance Test (PPT). Tinetti and PPT were also used at the end of each admission to assess the outcomes in terms of motor and functional performance.

Results: Each three-week period of treatment resulted in highly significant ( P < 0.001) improvements of motor performance and daily life activities. The average increase was 4.7 for Tinetti and 5.21 for PPT scores. No carry-over effect from one admission to the next was apparent but at the same time, no motor decline was detected over two years, indicating that patients maintained a constant level of functional, cognitive as well as motor performance.

Conclusions: Intensive rehabilitation treatments may positively influence the maintenance of functional and motor performance in patients with Huntington's disease.

Randomized clinical trials in Clinical Rehabilitation

A randomized clinical trial (RCT) is currently the strongest method for evaluating interventions in clinical practice. RCTs also provide the politically most powerful form of evidence. However it is not necessarily agreed what constitutes an RCT. This editorial explores what might be included within the rubric of ‘randomized clinical trial' (and randomized controlled trial) by considering the reasons for using randomization and controls, and by discussing the definitions of clinical and trial. It suggests that the definition used in the Cochrane Glossary is too restricted and needs revision.

Effects of home exercises on motor performance in patients with Parkinson's disease

Objective: To investigate the effect of home exercises on the motor performance of patients with Parkinson's disease.

Design: A prospective blinded study with allocation of patients into their groups by alternate weeks.

Setting: A University Hospital neurology and physiotherapy department.

Subjects: Recruited from a movement disorders outpatient clinic of Cerrahpasa School of Medicine diagnosed with Parkinson's disease, classified as Hoehn and Yahr Grades I, II and III.

Interventions: Patients who fulfilled the inclusion criteria were recruited to the study. Each patient was evaluated at the end of first and second month after the baseline evaluation. Patients were divided into two groups. Those in the first and third week were put in the exercise group and second and fourth week in the control group. Patients in the exercise group (n=15) were given a schedule of exercises to undertake at home; the others (n=15) did not receive this instruction.

Measures: Ten- and 20-m walking test, first pace length, pace number in 10 m, walking around a chair, Nine Hole Peg Board (NHPB) test.

Results: Following the home exercise programme, patients in the exercise group showed improvement in walking 10 and 20 m, time elapsed to complete walking around a chair and length of the first pace length, and in the motor performance of both hands (p < 0.001).

Conclusions: A home-based rehabilitation programme for patients with Parkinson's disease helped to improve motor performance compared to patients who did not take advantage of a regular, professionally designed exercise programme.

A Meta-Analysis of Nonpharmacological Interventions for People With Parkinson’s Disease

Nonpharmacological interventions are important in providing care for Parkinson’s disease (PD) patients. However, there is limited evidence related to their impacts on health-related quality of life (HRQOL). We aimed to examine the effectiveness of nonpharmacological interventions for improving the HRQOL of PD patients. Articles published in peer-reviewed journals from 2000 to 2015 were searched through electronic searching, computerized author searching, and footnote chasing. A meta-analysis was performed using the RevMan 5.3 program. Overall, effect size for the studies ( n = 18) was −4.17 with 95% confidence interval (CI) from −7.63 to −0.70 ( Z = 2.36, p = .02), indicating positive effects of nonpharmacological interventions on HRQOL. In subgroup analysis regarding the intervention types, the effect size of exercise programs was −5.73 with 95% CI of −11.36 to −0.10 ( Z = 2.00, p = .05). Thus, nonpharmacological interventions, and particularly exercise programs, were effective in improving the HRQOL of PD patients.

Epidemiology of inpatient stay in Parkinson's disease in the United States: Insights from the Nationwide Inpatient Sample

The total number of people living with Parkinson's disease (PD) worldwide is expected to double by 2030. The risk factors for emergency department visits in PD patients have been described before, however, there is limited data on inpatient hospitalizations of PD patients. We derived our study cohort from the Nationwide Inpatient Sample (NIS) database from 2002-2011. The NIS is a stratified 20% sample of discharges from all U.S. hospitals. We extracted causes of hospitalization using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes and calculated inpatient mortality, length of stay and cost. Further, the significance of trends over 10 years was assessed. A total of 3,015,645 (weighted) admissions of PD patients were documented from 2002-2011. Pneumonia, urinary tract infection (UTI), septicemia and aspiration pneumonitis were the most common causes of admission, of which incidence of sepsis and UTI was trending up. Of all causes, 3.9% of the admissions resulted in inpatient mortality. Inpatient mortality for PD patients decreased from 4.9% in 2002 to 3.3% in 2011 (p<0.001). The median length of stay has also steadily declined from 3.6days in 2002 to 2.3days in 2011. However, the inflation-adjusted cost of care has been steadily rising, from $22,250 per hospitalization in 2002 to $37,942 in 2011. We conclude that the epidemiology of inpatient admissions in PD has changed significantly over the last decade. Our study underscores the need for future, in-depth prospective studies to explore this changing disease spectrum to design preventive measures and targeted interventions.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

Specialist rehabilitation for people with Parkinson’s disease in the community: a randomised controlled trial

Background

Multidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.

Objectives

(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.

Design

Pragmatic three-parallel group randomised controlled trial.

Setting

Community, county of Surrey, England, 2010–11.

Participants

People with Parkinson’s, at all stages of the disease, and live-in carers.

Interventions

Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).

Main outcome measures

Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.

Results

A total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).

Conclusions

Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.

Study registration

Current Controlled Trials: ISRCTN44577970.

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

Virtual house calls for Parkinson disease (Connect.Parkinson): study protocol for a randomized, controlled trial

Background

Interest in improving care for the growing number of individuals with chronic conditions is rising. However, access to care is limited by distance, disability, and distribution of doctors. Small-scale studies in Parkinson disease, a prototypical chronic condition, have suggested that delivering care using video house calls is feasible, offers similar clinical outcomes to in-person care, and reduces travel burden.

Methods/Design

We are conducting a randomized comparative effectiveness study (Connect.Parkinson) comparing usual care in the community to usual care augmented by virtual house calls with a Parkinson disease specialist. Recruitment is completed centrally using online advertisements and emails and by contacting physicians, support groups, and allied health professionals. Efforts target areas with a high proportion of individuals not receiving care from neurologists. Approximately 200 individuals with Parkinson disease and their care partners will be enrolled at 20 centers throughout the United States and followed for one year. Participants receive educational materials, then are randomized in a 1:1 ratio to continue their usual care (control arm) or usual care and specialty care delivered virtually (intervention arm). Care partners are surveyed about their time and travel burden and their perceived caregiver burden. Participants are evaluated via electronic survey forms and videoconferencing with a blinded independent rater at baseline and at 12 months. All study activities are completed remotely.

The primary outcomes are: (1) feasibility, as measured by the proportion of visits completed, and (2) quality of life, as measured by the 39-item Parkinson’s Disease Questionnaire. Secondary outcomes include measures of clinical benefit, quality of care, time and travel burden, and caregiver burden.

Discussion

Connect.Parkinson will evaluate the feasibility and effectiveness of using technology to deliver care into the homes of individuals with Parkinson disease. The trial may serve as a model for increasing access and delivering patient-centered care at home for individuals with chronic conditions.

Trial registration

This trial was registered on clinicaltrials.gov on January 8, 2014 [NCT02038959].

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-465) contains supplementary material, which is available to authorized users.

What matters to people with Parkinson's disease living in Australia?

Patient-centred care is increasingly being recognised as an integral aspect of improving the quality of health care services. There has been a recent interest in taking a patient-centred approach to Parkinson's disease (PD) care by involving patients in shared decision making, as well as providing access to multidisciplinary teams of medical practitioners, PD nurse specialists, and allied health professionals. However, to our knowledge there are no data regarding patient preferences for interventions in PD management. The present study examined the relative importance of issues regarding quality of life for people living with PD in Australia using a self-administered survey. Overall, respondents ranked more research funding in PD (mean rank, 340.42) as the most important issue, access to PD nurses (285.50) in second place, followed by access to multidisciplinary facilities/clinics with allied health professionals (283.39) in third place, subsidised PD treatments (233.50) in fourth place, and better general practitioner education (184.69) as the least important issue of the options offered. There was a statistically significant difference between the five issues (H[4] = 65.38, p < 0.001). Within the framework of patient-centred care, public funding allocations perhaps should be based on what patients want. As such, these findings suggest that for people living with a chronic, progressive, incurable illness, research is highly valued.

Influence of functional movement rehabilitation on quality of life in people with Parkinson's disease

[Purpose] Parkinson's disease is one of the most frequent diseases of the central nervous system. Thorough knowledge of reasons for movement defects may contribute to the ability to quality of life at a good level as far as motor abilities are concerned. The aim of the study was to evaluate the influence of functional movement rehabilitation on the degree of intensity of movement symptoms in Parkinson's disease. [Subjects] The research was carried out in people diagnosed with stage III Parkinson's disease, according to the Hoehn and Yahr scale classification. [Methods] In order to establish the clinical state of patients, parts I, II, and III of the Unified Parkinson's Disease Rating Scale, the Schwab and England Activities of Daily Living scale, and the quality of life in Parkinson's disease questionnaire were applied. The intervention group took part in 60 minutes of functional movement rehabilitation twice a week for a period of 15 weeks. The main emphasis was placed on the ability to cope with everyday activities. [Results] A significant difference in scores for the given scales between before and after research the intervention period was observed in the intervention group. [Conclusion] The obtained results revealed positive that the influence of applied rehabilitation program had a positive influence on the degree of intensity of movement symptoms in people with Parkinson's disease.