Physical, Occupational Therapy Ineffective in Parkinson's

Pauline Anderson

January 19, 2016

Patients with mild to moderate Parkinson's disease don't appear to benefit much from physical therapy (PT) or occupational therapy (OT), a new study shows.

The study, comparing PT and OT with no therapy, showed that these interventions were not associated with clinically meaningful improvements in activities of daily living or quality of life.

Researchers may have failed to find an effect because the therapy wasn't intense enough or didn't continue for long enough, said lead study author, Carl E. Clarke, MD, professor, clinical neurology, and honorary consultant neurologist, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom, told Medscape Medical News.

Dr Carl E. Clarke

"In patients with mild to moderate disease, if you don't give them a great deal of therapy, which is exactly what happened in this trial, then it doesn't have any effect on activities of daily living or quality of life."

The study, published online January 19 in JAMA Neurology, included 762 patients with PD who were randomly assigned to combined PT and OT or to no therapy. The therapy, delivered in the community or outpatient setting, was tailored to an individual's requirements.

The most frequent reason for a PT intervention was gait, physical conditioning, and "transfers" (eg, moving from the bed to a chair). The most frequent intervention for OT was for transfers, dressing, and grooming.

In the intervention group, the median therapy "dose" was 4 sessions of 58 minutes over 8 weeks of combined PT and OT.

The mean age of study participants was 70 years; 65% of patients were male. Median disease duration was 3.1 years, and most patients had mild to moderate disease.

The primary outcome was change in total Nottingham Extended Activities of Daily Living (NEADL) score, which measures how easy or difficult it is for patients to perform various activities, at 3 months. The NEADL includes more complex activities of daily living (ADLs), such as making a meal, cleaning, and traveling on public transport. A 2-point change in the NEADL scale represents becoming independent in, for example, stair climbing or crossing roads.

No Difference

The study found that the mean NEADL total score deteriorated by 1.5 points in the intervention group and 1.0 point in the control group (difference, 0.5 point; 95% confidence interval [CI], –0.7 to 1.7; P = .41). There was no difference in any of the individual categories of the NEADL score.

The mean Parkinson Disease Questionaire-39 (PDQ-39) summary index deteriorated by 2.4 points in both groups (difference, 0.007 points; 95% CI, –1.5 to 1.5; P = .99), with no difference in any of the 8 domains of this scale. The slight improvement on the EuroQol-5D quotient in the therapy group compared to the control group was borderline significant (P = .04).

There was also no clinically meaningful difference in the outcomes at 15 months (or a year after the end of the therapy).

The authors attributed the absence of any motor effect or response in ADLs to several factors, including the low "dose" of intervention.

"If you only give people 4 hours worth of assessment and therapy time from physiotherapy and OT, it's not going to have a meaningful effect," said Dr Clarke. "We need to find better forms of therapy."

Therapists have told him that patients need to be seen regularly — for at least an hour and at least on a weekly basis — and that they need "progression" in their program, with exercises getting "tougher" with practice, said Dr Clarke.

He noted that stroke rehabilitation therapies that are more aggressive and very "prescriptive" (eg, seeing a physical therapist once a week for 8 weeks and doing progressively more intensive exercises at home) stand a better chance of success.

"But then, it's a different condition and it's difficult to extrapolate across different diseases, especially to a chronic condition like PD."

Another reason the intervention may not have worked was that it was too early in the disease. Patients with mild PD do quite well, with many remaining at work and not yet having problems with falling, said Dr Clarke.

"So perhaps it's not surprising that there wasn't too much for the therapist to do."

Although it's possible that the patients had such good baseline NEADL scores that they couldn't improve much, the authors pointed out that subgroup analysis showed there was still no response in patients with more severe baseline scores.

The study results, said Dr Clarke, "allow us to refocus what we're doing, and not just to be more efficient, but more cost-effective as well."

Another research group is studying a more prescriptive exercise program in patients with more severe disease, which includes a fall prevention program and an exercise program, said Dr Clarke.

Meanwhile, his research team is studying the effect of speech and language therapy on patients with PD.

Aerobic Exercise

In an accompanying editorial, J. Eric Ahlskog, PhD, MD, Department of Neurology, Mayo Clinic, Rochester, Minnesota, said referrals to PT or OT in patients with PD should be for specific problems that are likely to benefit, for example, gait freezing, imbalance, and immobilized limbs.

He also suggested that PT should incorporate ongoing aerobic exercise, which may slow the progression of PD. There's substantial, albeit indirect, evidence for regular vigorous exercise and aerobic fitness possibly providing a neuroprotective effect, writes Dr Ahlskog.

"Habitually exercising humans have evidence of significantly larger brain cognitive regions, better cortical connectivity (functional magnetic resonance imaging), better cognitive scores, and reduced later frequencies of PD, dementia, and mild cognitive impairment," he notes.

The structured aerobic exercise program Dr Ahlskog envisions would be targeted to the individual patient with PD. "There is no one-size-fits-all program for exercise and all aerobic exercise options should be on the table," he writes.

Dr Clarke agreed that aerobic exercise can help with motor function and is possibly neuroprotective, but getting patients with PD to adhere to such a program is a challenge. He stressed that patients need to be engaged.

"Our next big hurdle is to persuade the patient with early PD, who very often wants to just get on with life and doesn't particularly want to have to spend an hour on the treadmill every other day, to engage in some form or regular exercise, whatever it may be."

Dr Clarke received honoraria for lectures, travel expenses for conferences, and unrestricted educational grants from AbbVie, Britannia, Teva-Lundbeck, and UCB. Dr Ahlskog has disclosed no relevant financial relationships.

JAMA Neurol. Published online January 19, 2016. Abstract Editorial

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