Samyra Keus

Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research†

Physical therapy is often prescribed in Parkinsons disease. To facilitate the uniformity and efficacy of this intervention, we analyzed current evidence and developed practice recommendations. We carried out an evidence‐based literature review. The results were supplemented with clinical expertise and patient values and translated into practice recommendations, developed according to international standards for guideline development. A systematic literature search yielded 6 systematic reviews and 23 randomized controlled trials of moderate methodological quality with sufficient data. Six specific core areas for physical therapy were identified: transfers, posture, reaching and grasping, balance, gait, and physical capacity. We extracted four specific treatment recommendations that were based on evidence from more than two controlled trials: cueing strategies to improve gait; cognitive movement strategies to improve transfers; exercises to improve balance; and training of joint mobility and muscle power to improve physical capacity. These practice recommendations provide a basis for current physical therapy in Parkinsons disease in everyday clinical practice, as well as for future research in this field.

Physical therapy in Parkinson's disease: evolution and future challenges

Even with optimal medical management using drugs or neurosurgery, patients with Parkinsons disease (PD) are faced with progressively increasing mobility problems. For this reason, many patients require additional physical therapy. Here, we review the professional evolution and scientific validation of physical therapy in PD, and highlight several future challenges. To gain insight in ongoing, recently completed or published trials and systematic reviews, we performed a structured literature review and contacted experts in the field of physical therapy in PD. Following publication of the first controlled clinical trial in 1981, the quantity and quality of clinical trials evaluating the efficacy of physical therapy in PD has evolved rapidly. In 2004 the first guideline on physical therapy in PD was published, providing recommendations for evidence‐based interventions. Current research is aiming to gather additional evidence to support specific intervention strategies such as the prevention of falls, and to evaluate the implementation of evidence into clinical practice. Although research focused on physical therapy for PD is a relatively young field, high‐quality supportive evidence is emerging for specific therapeutic strategies. We provide some recommendations for future research, and discuss innovative strategies to improve the organization of allied health care in PD, making evidence‐based care available to all PD patients.

Efficacy of community-based physiotherapy networks for patients with Parkinson's disease: a cluster-randomised trial

BACKGROUND Many patients with Parkinsons disease are treated with physiotherapy. We have developed a community-based professional network (ParkinsonNet) that involves training of a selected number of expert physiotherapists to work according to evidence-based recommendations, and structured referrals to these trained physiotherapists to increase the numbers of patients they treat. We aimed to assess the efficacy of this approach for improving health-care outcomes. METHODS Between February, 2005, and August, 2007, we did a cluster-randomised trial with 16 clusters (defined as community hospitals and their catchment area). Clusters were randomly allocated by use of a variance minimisation algorithm to ParkinsonNet care (n=8) or usual care (n=8). Patients were assessed at baseline and at 8, 16, and 24 weeks of follow-up. The primary outcome was a patient preference disability score, the patient-specific index score, at 16 weeks. Health secondary outcomes were functional mobility, mobility-related quality of life, and total societal costs over 24 weeks. Analysis was by intention to treat. This trial is registered, number NCT00330694. FINDINGS We included 699 patients. Baseline characteristics of the patients were comparable between the ParkinsonNet clusters (n=358) and usual-care clusters (n=341). The primary endpoint was similar for patients within the ParkinsonNet clusters (mean 47.7, SD 21.9) and control clusters (48.3, 22.4). Health secondary endpoints were also similar for patients in both study groups. Total costs over 24 weeks were lower in ParkinsonNet clusters compared with usual-care clusters (difference euro727; 95% CI 56-1399). INTERPRETATION Implementation of ParkinsonNet networks did not change health outcomes for patients living in ParkinsonNet clusters. However, health-care costs were reduced in ParkinsonNet clusters compared with usual-care clusters. FUNDING ZonMw; Netherlands Organisation for Scientific Research; Dutch Parkinsons Disease Society; National Parkinson Foundation; Stichting Robuust.

The ParkinsonNet concept: Development, implementation and initial experience†

The quality and efficiency of allied health care in Parkinsons disease (PD) must be improved. We have developed the ParkinsonNet concept: a professional regional network within the catchment area of hospitals. ParkinsonNet aims to: (1) improve PD‐specific expertise among allied health personnel, by training a selected number of therapists according to evidence‐based guidelines; (2) enhance the accuracy of referrals by neurologists; (3) boost patient volumes per therapist, by stimulating preferred referral to ParkinsonNet therapists; and (4) stimulate collaboration between therapists, neurologists, and patients. We describe the procedures for developing a ParkinsonNet network. Our initial experience with this new concept is promising, showing an increase in PD‐specific and a steady rise in the patient volume of individual therapists.

Allied health care in Parkinson's disease: referral, consultation, and professional expertise.

There is evidence for the efficacy of allied health care in Parkinsons disease (PD). However, barriers exist that hamper implementation of evidence into daily practice. We conducted a survey to investigate: (1) to what extent PD patients currently utilize allied health care for relevant problems in the core areas of allied health care and (2) the level of PD‐specific expertise among allied health professionals. Questionnaires were sent to 260 patients and 297 allied health professionals. Referral rates were 63% for physical therapy, 9% for occupational therapy, and 14% for speech therapy. PD patients with problems that can potentially be alleviated by input from allied health professionals are often not being referred. Furthermore, most patients were treated by allied health professionals who lacked PD‐specific expertise. Current referral to and delivery of allied health care in PD are suboptimal. Evidence‐based guidelines for allied health care in PD and active implementation of these guidelines are needed.

Allied health care interventions and complementary therapies in Parkinson's disease

Allied health care and complementary therapies are used by many patients with Parkinsons disease (PD). For allied health care, supportive scientific evidence is gradually beginning to emerge, and interventions are increasingly integrated in the treatment programs for PD patients. To evaluate whether such multidisciplinary programs are justifiable, we review the literature of allied health care and complementary therapies in PD. According to the level of available evidence, we provide recommendations for clinical practice. Finally, we discuss the need for an improved organization of allied health care, and identify topics for future research to further underpin the pros and cons of allied health care and complementary therapies in PD.

The ParkinsonNet trial: Design and baseline characteristics†

The companion paper describes how implementation of professional networks (ParkinsonNet) may improve the quality and efficiency of allied health care in Parkinsons disease (PD). We designed a cluster‐randomized controlled trial to evaluate this ParkinsonNet concept for one allied health discipline, namely physical therapy. Here we describe the study design and baseline characteristics. The design fully complies with the CONSORT criteria. Sixteen regions in the Netherlands were randomly divided into eight experimental regions where a ParkinsonNet was implemented, and eight control regions where the organization of care was left unchanged (usual care). Participating patients were followed for 6 months to evaluate the implementation process, health benefits and costs of the intervention. In the ParkinsonNet regions, 46 therapists were trained and 358 patients were included. In the usual care regions, 341 patients were included. Baseline characteristics of participants in the ParkinsonNet and control clusters were comparable. With 699 participating patients, this is the largest allied health study in PD to date.

Treatment of lateral epicondylitis in general practice

Introduction In January 1997, the Dutch College of General Practitioners (NHG) published clinical guidelines for lateral epicondylitis.’ Taking into account the benign natural course of the complaints, and the lack of evidence for the effectiveness of active interventions, the NHG guidelines recommend a wait-and-see policy, consisting of ergonomic advice and prescription of paracetemol or non-steroidal anti-inflammatory drugs, if necessary. Although short-term (2-8 weeks) benefit from corticosteroid injections has been the guidelines recommend corticosteroid injections as an alternative for patients with persisting complaints. In order to investigate the treatment preferences of general practitioners (GPs), and the determinants of their choice of treatment, including the influence of the recently published clinical guidelines, a survey was carried out.

Physical and occupational therapy

The graduate entry-level program in Physical Therapy is a professional entry level program designed to prepare students for licensure to practice as physical therapists. The program is accredited by the Commission on Accreditation in Physical Therapy Education of the American Physical Therapy Association. The Doctor of Physical Therapy program (DPT) was granted re-accreditation status by the Commission on Accreditation in Physical Therapy Education (CAPTE) in May 2016. Prospective students having questions about the programs accreditation status should contact:

The European Physiotherapy Guideline for Parkinson’s Disease: Implications for Neurologists

The evidence for physiotherapy is growing, showing a positive impact on functional activities involving gait, transfers and balance. Specific recommendations for physiotherapists, physicians and people with Parkinsons disease were published in the European Physiotherapy Guideline for Parkinsons disease. Here, we summarize the referral criteria, highlight the importance of accurate referral to specialized physiotherapists, and emphasize the potential benefits of expert care. As such, this paper offers very practical guidance for clinicians working with Parkinsons disease patients and who consider physiotherapy treatments for their patients.