Multidisciplinary care for people with Parkinson’s disease

Traditionally, management of Parkinson’s disease has involved a single medical specialty, often a neurologist or geriatrician, providing treatment based mainly on dopaminergic medication and other pharmacological interventions. This is usually effective in reducing the classic motor symptoms, such as bradykinesia (slowness of movement), and reducing disability.¹ However, this approach is of limited benefit when treating the non-motor symptoms of Parkinson’s including depression, anxiety, cognitive decline, autonomic dysfunction (e.g. bladder disturbances, sweating, erectile dysfunction) and sensory problems. Few of these non-motor symptoms respond satisfactorily to dopaminergic treatment. In fact, some may even worsen with this type of medication, such as orthostatic hypotension or hallucinations.¹

Many people with Parkinson’s believe ‘gold standard care’ should involve a multidisciplinary team with care tailored to their specific needs and those of their family and carers. Such multidisciplinary treatment may involve a number of allied health specialists, including physiotherapists, occupational therapists and speech and language therapists – as well as support and advice from dieticians, social workers and sexologists – to complement standard medical treatment in the management of both motor and non-motor symptoms. While the neurologist determines disease severity and optimises medical treatment to reduce symptoms, allied health therapists work to minimise the impact of the disease process and improve the person’s participation in everyday activities.¹

Much of the information about the benefits of allied healthcare in Parkinson’s comes from clinical experience, but the evidence-base backing its use requires further development. Fortunately, good scientific evidence is now beginning to emerge for the contribution of the individual allied health disciplines (in particular for physiotherapy), but much more work is needed to demonstrate the cost-effectiveness of the integrated multidisciplinary approach.^1,2

Physiotherapy is the treatment of physical dysfunction or injury by physical means rather than with medication. One physical intervention, with mounting evidence of success, is the use of external cueing techniques – where external sensory cues prompt a person to move, such as rhythmic auditory cues. These can help people with Parkinson’s to overcome their mobility deficits and alleviate some non-motor symptoms.

An evidence-based guideline outlining the different physiotherapy treatments effective in the management of Parkinson’s has been developed³ and later updated in 2008.⁴ The guideline has been adopted by the Association of Physiotherapists in Parkinson’s Disease Europe (APDDE) and is available online (www.appde.eu). It contains recommendations for clinical practice in Parkinson’s, including several strong recommendations which are based on high quality randomised studies. One recommendation is implementing cuing strategies. Such strategies afford many physical benefits – such as improved gait, posture and ability to stand up from a sitting position – and also improve people’s confidence to carry out activities without falling. This can lead to an improved balance confidence, which may assist with relieving anxiety, a common non-motor symptom associated with depression.

Dancing is another useful technique recommended by physiotherapists and one hour of Argentine tango dancing has been found to correct both balance and gait.⁵ In a tango class, the music provides the auditory cue and the consecutive steps of the dance act as a movement strategy. Of course, the activity itself is a form of exercise which is hugely beneficial for both motor and non-motor symptoms.

However, whilst cueing strategies are certainly effective in the short term, more work remains necessary to determine how long term effects can be ascertained.⁶ In particular, work is needed to take cueing strategies out of the examination room and implement them under real life circumstances where cues are needed most.

The exercise therapy provided by a physiotherapist can enhance physical capacity (in terms of strength and balance), as well as gait, speed and health-related quality of life.⁷ Two treadmill training studies provided supporting evidence that exercise therapy can improve gait parameters, lower extremity tasks, increase muscle volume and enhance feelings of wellbeing, which is important for some non-motor symptoms, such as depression and anxiety.^8,9,10 An exercise programme will also improve fitness and, when combined with a variety of mental and social activities, can help alleviate fatigue. Other non-motor symptoms may also improve indirectly with exercise, although the supporting evidence mainly comes from studies in elderly subjects without Parkinson’s. For example, active people tend to sleep better and greater physical activity has been associated with a reduction in depression and improvements in cognition. Regular exercise may also help to slow down or prevent the development of osteoporosis, which is a common problem for people with Parkinson’s. A major challenge is to ascertain what each patient finds palatable and safe in terms of an exercise program that suits their own individual abilities and preferences. Achieving this should ensure an increase in physical activities. Good physiotherapists can act as coaches for patients to develop such tailor-made programs and a large clinical trial in the Netherlands – the ParkFit study¹¹ – is currently studying the merits of such a coaching role for physiotherapists in achieving lasting increases in daily physical activities.

The primary goal of occupational therapy is to help people to participate in the activities of everyday life. This can include adapting these activities to enhance people’s ability to perform, whilst modifying the environment to better support such participation.

In 2008, an evidence-based guideline was published for occupational therapy in Parkinson’s with recommendations covering referral, assessment techniques and treatment.¹² There is hardly any good scientific evidence for the effectiveness of occupational therapy in Parkinson’s, so recommendations were made based on data for physiotherapy and experience with occupational therapy in other conditions, such as dementia and multiple sclerosis, whenever these were felt to be relevant for Parkinson’s.

The guideline places a strong focus on encouraging self-management skills and addressing the needs of carers on issues related to activities and participation. Coaching the person with Parkinson’s in the careful planning of daily and weekly routines, taking factors such as energy levels, medication effects and speed of task performance, is also highlighted. A daily or weekly activity plan may also provide a structure for people with problems in initiating or planning activities.

An occupational therapist can also provide advice on specialist equipment or changes to the physical environment to optimise the use of motor or cognitive strategies and activity performance.

By addressing obstacles – e.g. fatigue, motivation, social restrictions and psychological issues such as depression, as well as other non-motor symptoms – an occupational therapist can help a person adapt more effectively as Parkinson’s progresses and retain independence. Communication issues can be addressed, whilst the home can be adapted to reduce concerns surrounding bowel problems.

The role of a speech and language therapist is to help people to communicate to the best of their ability by assessing and treating speech, language and communication problems.

In 2008, an evidence-based guideline was published for speech and language therapy in Parkinson’s.¹² It included  recommendations to help speech and language therapists in clinical decision making and covered both assessment and treatment. The treatment goals address three main areas: speech impairment (hypokinetic dysarthria), swallowing disorders and drooling.

Two of the strongest recommendations were made in the area of speech. One recommendation is to limit dysarthria assessment in Parkinson’s by establishing whether or not people should receive specific intensive treatment (Lee Silverman Voice Treatment – LSVT – or Pitch Limiting Voice Treatment – PLVT).^13,14 The other strong recommendation is that if PLVT or LSVT are recommended, they should be given at least three times a week for a minimum of four weeks to gain the maximum benefit.¹² Another study showed that videophone-delivered speech therapy can be costeffective.¹⁵

In the field of drooling there is new evidence that botulinum toxin injections can reduce saliva production, but without improving swallowing physiology.¹⁶ In the field of dysphagia, a small pilot study demonstrated that the daily use of effortful swallowing (assisted with biofeedback) for two weeks was helpful in reducing dysphagia in Parkinson’s.¹⁷

A multidisciplinary team approach, combining both pharmacological and non-pharmacological treatments, would appear to be the optimal approach for such a complex and multifaceted condition as Parkinson’s. To address this need, specialist Parkinson’s centres have begun to implement integrated and multidisciplinary healthcare programmes within their clinical practice. The UK based National Institute for Health and Clinical Excellence (NICE) is an independent organisation responsible for providing national  on promoting good health and preventing and treating ill health. Their guidelines recommend regular access to a broad range of medical and allied health professionals.¹⁸

Good team work and communication, including shared goal setting and contribution to treatment plans, are fundamental to the success of the multidisciplinary approach to care in Parkinson’s. The goals should be defined not only around disease severity and symptoms, but should also consider mobility, independence and relationships. Importantly, the treatment plan should address the individual needs of each person and must engage the immediate carer, family and friends who play a critical role in integrating care strategies into daily activities and routines.¹

An optimal multidisciplinary approach will also include the carers’ needs. For example, occupational therapy may help carers cope with more complex situations, thereby delaying the need for assisted or residential care for the person with Parkinson’s.¹

Although scientific evidence is available for certain allied healthcare interventions, more good quality clinical trials are needed to underpin the merits of the multidisciplinary approach, including studies to find out whether they are more effective in particular groups of patients. For example, cognitive impairment may reduce understanding of the recommendations or the ability to memorise new movement strategies, so specific studies need to target subgroups of patients with and without cognitive decline.¹

The evidence for an integrated multidisciplinary approach is still limited and more work is needed to support the general feeling that multidisciplinary care improves the quality of care and leads to a better outcome for patients. There is also a need to determine which specific elements should be included in the multidisciplinary approach, and whether a ‘one size fits all treatment’ is as good as an individually tailored approach.¹

One approach which has been successful is ParkinsonNet,¹⁹ an innovative healthcare organisation created in the Netherlands to help people with Parkinson’s find information, make decisions in relation to their specific healthcare needs and identify Parkinson’s experts that offer optimal treatment, thus building their own health network.

Launched in 2004, ParkinsonNet currently has almost 700 physical therapists, 250 occupational therapists and 250 speech and language therapists working together across more than two thirds of the country. These professionals have the opportunity to discuss treatment options together to find a fully-complementary healthcare plan, whilst the patient can follow the discussions and participate if they wish. The goal is that, by 2011, the whole of the Netherlands will have adopted the ParkinsonNet networks, plus the disciplines involved in the care for Parkinson’s families will also be added. Moreover, according to a large, randomised clinical trial involving almost 700 patients,²⁰ ParkinsonNet markedly improved the quality of care for those with the disease, whilst making considerable cost savings.

Of course, in this era of economic concerns, we must look critically at budgets and the cost-effectiveness of the multidisciplinary approach. Offering a whole team to the patient, instead of just a solitarily working neurologist, is obviously more costly in the short term. However, I am personally convinced that this initial investment will be offset by great profits in the long term, including greater mobility and independence, fewer disease complications, such as falls or fall-related injuries, and a reduced need for costly home support or even nursing home admission. And most importantly, a multidisciplinary approach will help to improve the quality of life, and this by itself is more than worth the investment made!

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