A Delphi Survey of Best Practice Occupational Therapy for Parkinson's Disease in the United Kingdom

This study was designed to determine the character of best occupational therapy practice for Parkinson's disease in the United Kingdom. Two hundred and forty-two occupational therapists treating people with Parkinson's disease were sent a Delphi survey containing statements about best practice and asked to indicate their level of agreement with each statement. The second survey contained the same list of statements, with group levels of agreement from the first round for each statement. The respondents re-rated their answers and gave their opinion on the efficacy of various interventions.

One hundred and fifty occupational therapists (62%) completed both rounds. Ninety-nine per cent of the respondents agreed that Parkinson's disease required lifelong provision of occupational therapy, within multidisciplinary teams, and that the social and psychological aspects of the disease were as important as the physical ones. The occupational therapists had confidence in many techniques for achieving physical, social and psychological goals. However, 40% of the respondents could not rate the efficacy of social and psychological techniques owing to a lack of knowledge.

There was a high level of consensus nationally on the character of best practice occupational therapy for Parkinson's disease. The survey highlighted a need for more postgraduate training, especially in psychological techniques.

A Survey of Current Occupational Therapy Practice for Parkinson's Disease in the United Kingdom

Little is known about the current character of occupational therapy practice for Parkinson's disease in the United Kingdom. The study aimed to document this in order to inform plans for a future multicentre randomised controlled trial.

Two hundred and forty-two occupational therapists that treated people with Parkinson's disease were sent a questionnaire regarding demographics, service organisation and therapy content. One hundred and sixty-nine occupational therapists (70%) responded. They had worked with people with Parkinson's disease for a median of 6 years and personally treated a median of 15 people with Parkinson's disease annually. Most (86%) were at senior grade or above; 87% worked in the National Health Service and 12% in social services. Forty per cent worked in specialist Parkinson's disease clinics. Most (79%) felt that they needed more specialist postgraduate training.

Occupational therapists are employed in both health and social care settings. The character of the occupational therapy is often determined by the location in which it is provided. Current occupational therapy appears to focus on functional activities rather than on the wider social and psychological aspects of occupation. Many occupational therapists felt that they needed more specialist postgraduate training to treat people with Parkinson's disease effectively.

Adherence therapy improves medication adherence and quality of life in people with Parkinson's disease: a randomised controlled trial

BACKGROUND

Many factors are associated with medication non-adherence in Parkinson's disease (PD), including complex treatment regimens, mood disorders and impaired cognition. However, interventions to improve adherence which acknowledge such factors are lacking. A phase II randomised controlled trial was conducted investigating whether Adherence Therapy (AT) improves medication adherence and quality of life (QoL) compared with routine care (RC) in PD.

METHODS

Eligible PD patients and their spouse/carers were randomised to intervention (RC plus AT) or control (RC alone). Primary outcomes were change in adherence (Morisky Medication Adherence Scale) and QoL (Parkinson's Disease Questionnaire-39) from baseline to week-12 follow up. Secondary outcomes were MDS-UPDRS (part I, II, IV), Beliefs about Medication Questionnaire (BMQ), EuroQol (EQ-5D) and the Caregiving Distress Scale. Blinded data were analysed using logistic and linear regression models based on the intention-to-treat principle.

RESULTS

Seventy-six patients and 46 spouse/carers completed the study (intervention: n = 38 patients, n = 24 spouse/carers). At week-12 AT significantly improved adherence compared with RC (OR 8.2; 95% CI: 2.8, 24.3). Numbers needed to treat (NNT) were 2.2 (CI: 1.6, 3.9). Compared with RC, AT significantly improved PDQ-39 (-9.0 CI: -12.2, -5.8), BMQ general harm (-1.0 CI: -1.9, -0.2) and MDS-UPDRS part II (-4.8 CI: -8.1, -1.4). No significant interaction was observed between the presence of a spouse/carer and the effect of AT.

CONCLUSION

Adherence Therapy improved self-reported adherence and QoL in a PD sample. The small NNT suggests AT may be cost-effective. A larger pragmatic trial to test the efficacy and cost-effectiveness of AT by multiple therapists is required.

Systematic review of antidepressant therapies in Parkinson's disease☆

Depression is the most common psychiatric disturbance in Parkinson's disease. We conducted a Cochrane systematic review to assess the efficacy and safety of antidepressant therapies in idiopathic Parkinson's disease. Relevant trials were identified from electronic databases, reference lists and queries to antidepressant manufacturers. Three randomised controlled trials examined oral antidepressants in 106 patients with Parkinson's disease. No eligible trials of electroconvulsive or behavioural therapy were found. In the first arm of the crossover trial by Andersen et al. (n=22), nortriptyline treated patients showed a larger improvement than placebo in a unique depression rating scale after 16 weeks although significance levels were not provided. A parallel group trial by Wermuth et al. (n=37) did not show any significant difference between citalopram and placebo in Hamilton score after 52 weeks. Rabey et al. (n=47) performed an open-label trial comparing fluvoxamine with amitriptyline. Similar numbers in each group had a 50% reduction in Hamilton score after 16 months. Major side effects including visual hallucinations and confusion were reported with fluvoxamine and amitriptyline. Insufficient data on the effectiveness and safety of antidepressant therapies in Parkinson's disease are available on which to make recommendations for their use. Large scale randomised controlled trials are urgently required.

Beta-blocker therapy for tremor in Parkinson's disease

BACKGROUND

The tremor of Parkinson's disease can cause considerable disability for the individual concerned. Traditional antiparkinsonian therapies such as levodopa have only a minor effect on tremor. Beta-blockers are used to attenuate other forms of tremor such as Essential Tremor or the tremor associated with anxiety. It is thought that beta-blockers may be of use in controlling the tremor of Parkinson's disease.

OBJECTIVES

To compare the efficacy and safety of adjuvant beta-blocker therapy against placebo for the treatment of tremor in patients with Parkinson's disease.

SEARCH STRATEGY

Electronic searches of MEDLINE, EMBASE, SCISEARCH, BIOSIS, GEROLIT, OLDMEDLINE, LILACS, MedCarib, PASCAL, JICST-EPLUS, RUSSMED, DISSERTATION ABSTRACTS, SIGLE, ISI-ISTP, Aslib Index to Theses, The Cochrane Controlled Trials Register, Clinicaltrials.gov, metaRegister of Controlled Trials, NIDRR, NRR and CENTRAL were conducted. Grey literature was hand searched and the reference lists of identified studies and reviews examined. The manufacturers of beta-blockers were contacted.

SELECTION CRITERIA

Randomised controlled trials of adjuvant beta-blocker therapy versus placebo in patients with a clinical diagnosis of idiopathic Parkinson's disease.

DATA COLLECTION AND ANALYSIS

Data was abstracted independently by two of the authors onto standardised forms and disagreements were resolved by discussion.

MAIN RESULTS

Four randomised controlled trials were found comparing beta-blocker therapy with placebo in patients with idiopathic Parkinson's disease. These were double-blind cross-over studies involving a total of 72 patients. Three studies did not present data from the first arm, instead presenting results as combined data from both treatment arms and both placebo arms. The risk of a carry-over effect into the second arm meant that these results were not analysed. The fourth study presented data from each arm. This was in the form of a mean total score for tremor for each group. Details of the baseline scores, the numbers of patients in each group and standard deviations were not provided, meaning that the magnitude and significance of any changes due to therapy could not be calculated. One study reported a substantial fall in heart rate in 14 of the 22 patients, with one patient withdrawing after his heart rate dropped to 56 beats per minute (baseline heart rate was not reported).

REVIEWER'S CONCLUSIONS

In view of this lack of evidence, it is impossible to determine whether beta-blocker therapy is effective and safe for the treatment of tremor in Parkinson's disease. The high frequency of bradycardia in one trial raises some concerns about the prescription of beta-blockers to normotensive elderly patients but the study was too small for the true degree of risk to be calculated.

Amantadine for dyskinesia in Parkinson's disease

BACKGROUND

Abnormal involuntary movements known as dyskinesias are amongst the most disabling side-effects of levodopa therapy. It is thought that amantadine, an NMDA-receptor antagonist, may reduce dyskinesias in patients with Parkinson's disease without worsening Parkinsonian symptoms.

OBJECTIVES

To compare the efficacy and safety of adjuvant amantadine therapy versus placebo in treating dyskinesia in patients with Parkinson's disease, already established on levodopa, and suffering from motor complications.

SEARCH STRATEGY

Electronic searches of The Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2001), MEDLINE (1966-2001), EMBASE (1974-2001), SCISEARCH (1974-2001), BIOSIS (1993-2001), GEROLIT (1979-2001), OLDMEDLINE (1957-1965), LILACS (1982-2001), MedCarib (17th Century - 2001), PASCAL (1973-2001), JICST-EPLUS (1985-2001), RUSSMED (1973-2001), DISSERTATION ABSTRACTS (2000-2001), SIGLE (1980-2001), ISI-ISTP (1990-2001), Aslib Index to Theses (2001), Clinicaltrials.gov (2001), metaRegister of Controlled Trials (2001), NIDRR (2001) and NRR (2001) were conducted. Grey literature was hand searched and the reference lists of identified studies and reviews examined. The manufacturers of amantadine were contacted.

SELECTION CRITERIA

Randomised controlled trials comparing amantadine with placebo in the treatment of dyskinesia in patients with a clinical diagnosis of idiopathic Parkinson's disease.

DATA COLLECTION AND ANALYSIS

Data was abstracted independently by NC and KD onto standardised forms and disagreements were resolved by discussion.

MAIN RESULTS

Three randomised controlled trials were found comparing amantadine with placebo in the treatment of dyskinesia in patients with idiopathic Parkinson's disease. Three trials were excluded on the basis that they had no control group and a further three did not state whether they randomised the treatment that participants received. The included trials were double-blind cross-over studies involving a total of 53 patients. All three studies failed to present data from the first arm, instead presenting results as combined data from both treatment arms and both placebo arms. Two trials had no wash-out interval between the treatment periods. In view of the risk of a carry-over effect into the second arm, the results of these trials were not analysed. The final trial had a one week wash-out interval but only examined 11 participants. One study reported side-effects of amantadine in 8 of the 18 participants, including confusion and worsening of hallucinations. Another reported reversible edema of both feet in one of eleven participants.

REVIEWER'S CONCLUSIONS

Due to lack of evidence it is impossible to determine whether amantadine is a safe and effective form of treatment for levodopa-induced dyskinesias in patients with Parkinson's disease.