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Study Questions Value of Physiotherapy, Occupational Therapy in PD

January 19, 2016

By Will Boggs MD

NEW YORK (Reuters Health) - Physiotherapy (PT) and occupational therapy (OT) did not improve activities of daily living (ADL) or quality of life (QoL) in patients with mild to moderate Parkinson's disease (PD) in the PD REHAB Trial.

PT and OT are traditionally used later in the course of PD, but previous reviews have failed to demonstrate substantial benefits of either therapy. Still, the UK National Institute for Health and Care Effectiveness (NICE) guidelines state that all patients should have access to both therapies.

Dr. Carl E. Clarke, from Sandwell and West Birmingham Hospitals National Health Service Trust, City Hospital, Birmingham, England, and colleagues in the PD REHAB Collaborative Group evaluated the clinical effectiveness and cost-effectiveness of individualized PT and OT in a randomized trial of 762 patients with mild to moderate PD.

The median number of therapy sessions was four, and the mean duration of therapy was eight weeks.

PT included gait, posture, balance, physical conditioning, and transfers as the most frequent interventions, and the most frequent OT interventions were for transfers, dressing and grooming, sleep and fatigue, indoor mobility, household tasks, and other environmental issues.

The mean Nottingham Extended ADL Scale (NEADL) score deteriorated to a similar extent in both groups (therapy and no therapy), as did the Parkinson Disease Questionnaire-39 (PDQ-39) summary index.

The EuroQol-5D quality of life measure was slightly better after therapy than after no therapy, but there was no difference in caregiver quality of life (as measured by the Short Form-12).

Adverse events did not differ between the treatment arms, according to the January 19 JAMA Neurology online report.

"Physiotherapy and OT using an individual goal-setting approach produced no clinically meaningful short- or medium-term benefits in ADL or QoL in patients with mild to moderate PD," the researchers conclude. "This evidence does not support the use of low-dose, goal-directed PT and OT in patients in the early stages of PD. Future research should explore the development and testing of more structured and intensive PT programs in patients with all stages of PD."

Dr. J. Eric Ahlskog ,from Mayo Clinic, Rochester, Minnesota, who wrote an editorial related to this report, told Reuters Health by email, "Many of my PD patients have very sedentary lives. Despite my strong encouragement to begin in aerobic exercise, I am doubtful that this is frequently adopted. That is where physical therapy intervention might well translate into meaningful outcomes."


"The simple scheme would include identifying the type of exercise(s) that would appeal to the individual, initiating that and serving as an exercise coach who pushes them slowly toward true physical fitness. This would entail several sessions early in the course and then sessions at intervals thereafter," he said.

"The reason that I focus on aerobic exercise is because the literature is robust on that specific intervention (resistance exercise may accomplish the same goals but with few good studies and certainly that is not something that can be studied in animals)," Dr. Ahlskog said. "Moreover, aerobic exercise in humans overlaps with the animal literature on exercise (i.e., running wheels, treadmills). However, aerobic exercise in humans requires hard work and ongoing participation."

"To engage in exercise, they need adequate and appropriately dosed carbidopa/levodopa dosage," Dr. Ahlskog explained. "For those PD patients that are doing well on no medications, no drugs are needed; however, once they start to slow down, adequate carbidopa/levodopa is necessary to not only optimize quality of life but (importantly in this context), facilitate engagement in exercise."

Dr. Jacki Liddle, occupational therapist from Queensland Brain Institute, University of Queensland, Australia, told Reuters Health by email, "The outcome measures are not likely to be sensitive to the intervention used. Participants started at a very mild level on the scale and thus had very little room for improvement. The interventions used seemed very low dose and low intensity compared to what has demonstrated efficacy."

"In addition, people with PD are likely to still be able to perform certain tasks, but change in the way that they do it - so those scales are unlikely to pick up changes that could make a meaningful difference to people's lives," Dr. Liddle said. "So while this study included a large number of participants, the outcome measures used mean the findings need to be interpreted with a great deal of caution."

"Future attention may also explore the best ways of measuring outcomes that are meaningful to people living with Parkinson's so we can also use these to help investigate the impact of therapies, and determine the optimal timing and intensity," Dr. Liddle concluded.

Dr. Clarke did not respond to a request for comments.

The UK National Institute for Health Research supported this research. Two coauthors reported relationships with pharmaceutical companies.


JAMA Neurol 2016.

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