new and appropriate goals for parkinson disease physical therapy

8/17/2019 New and Appropriate Goals for Parkinson Disease Physical Therapy.

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Copyright 2016 American Medical Association. All ri ghts reserved.

New and AppropriateGoals for Parkinson Disease

Physical TherapyJ. Eric Ahlskog, PhD, MD

Physical and occupational therapy have long been compo-

nents of Parkinson disease (PD) treatment. Prior to the ad-

vent of levodopa, this was a primary therapeutic modality.What is the current role for physical therapyin PD?Should ev-

eryone with PD be referred? Is it cost-effective? What should

be the therapeutic goals and program content?

In the United Kingdom, cost-effectiveness is an especially

relevantconsiderationin the contextof itssingle-payerNational

Health Service. The cost-effectivenessof routinereferral of pa-

tientswith earlier-stagePD forphysiotherapyand occupational

therapy was addressed in an

article in this edition of JAMA

Neurology. Half of more than

patients with PD from

across the United Kingdomwere randomized to standard prac-ticephysiotherapyand occupationaltherapy (median,; hour-

long therapy sessions). Compared with the control group, this

therapyintervention failed to meaningfully influencethe activi-

tiesof daily living or quality-of-life measures, withfollow-up at

andup to months. Theinvestigators concluded that, “This

evidencedoes notsupport theuse oflow-dose,patient-centered,

goal-directedphysiotherapyandoccupationaltherapyin patients

in the early stages of PD.” The authors cited prior studies that

tended to support this conclusion.

These results should be interpreted with attention to the

study details. Patients in this investigation had mild to mod-

erate PD and the enrollment criteria excluded patients whose

clinicians believed needed physical/occupational therapy.

Thus, one may conclude from this investigation that blanket

referralsof allpatients with earlier-stage PD forroutine physi-

cal or occupation therapy appears to be cost-ineffective.

Intuitively, certainPD-related symptoms shouldbenefitfrom

routinephysical therapystrategies,including problems such as

gaitfreezing,imbalance/fallrisk, or immobilizedlimbs. Patients

withPDwithshortenedstrideorreducedarmswingbenefitfrom

strategiesforconsciouslyincreasingattenuatedmovements.Such

circumscribed problemswere notthe focus of thisinvestigation.

The therapy schemes performed in this investigation are

also notable: “Physiotherapy and [occupationaltherapy] were

delivered…by qualified therapists working within the Na-tional Health Service (NHS) per local practice.” Such routine

physicaltherapy practices areuniversally establishedand have

been used for decadesin treating PD.Per convention,these pri-

marily focus on stretching, balance, posture, gait, and strate-

gies forfacilitatingactivities of daily living. More recently, pro-

tocols forenhancing movement amplitudes have beenadded

(eg, consciously focusing on increasing stride length and arm

movements). However, these conventional physical therapy

practices take no advantageof what has nowbecome increas-

ingly apparent: ongoing aerobic exercise may slow the pro-

gression of PD. Todate,it has not beenpartof physical thera-

pists’ job description to facilitate ongoing aerobic exercise.

The progression of PD extends far beyond dopaminergic

substrates and includes potential for levodopa-refractory de-

mentia, dysautonomia, and medication-unresponsive motorsymptoms. No medications are proven to slow such PD pro-

gression. However, there is substantial, albeit indirect, evi-

dence for regular vigorous exercise and aerobic fitness possi-

bly providing a neurop rotective effect. This comes from a

variety of investigations, which may be summarized as

follows.Animalstudies havedocumented exercise-related in-

creases of brain neurotrophic factors, synapticproteins,neu-

roplasticity factors, hippocampal neurogenesis, hippocam-

pal long-term potentiation, recovery from neurotoxins, and

enhanced memory. Habitually exercising humans have evi-

dence of significantlylargerbrain cognitive regions,bettercor-

tical connectivity (functional magnetic resonance imaging), better cognitive scores, and reduced later frequencies of PD,

dementia, and mild cognitive impairment.

This exerciseliterature posesthe question ofwhether na-

tionalhealth careadministrationsshould endorseand financially

underwrite aerobicexercise programsfor allwithPD.Thiswould

entail far more than single therapy sessions.Our culture tends

to reinforcea sedentarylifestyle,and newexercise habits would

need to be periodically monitored and reinforced. Such a PD

exercise program would necessarily begin with optimized

carbidopa/levodopa treatment, which is often necessary to

allow exercise. The envisioned therapy program would begin

with individualized selection of aerobic exercise routines that

wouldbe toleratedandmaintainedbyeach personwithPD.There

is no one-size-fits-allprogram forexercise and all aerobic exer-

cise options should beon thetable.Such a programwould nec-

essarily start modestly for some but with therapist-guided ad-

vances and, sometimes, with tough love.

A challenge forthoseendorsingsucha structured aerobicex-

ercise protocol is proof of benefit. A randomized clinical trial

among patients withPD is going to be highly susceptibleto con-

founding factors. Manyin our culture aredisinclinedto exercise

even in the absence of neurologic disease; maintaining persis-

tentadequatelevelsofaerobicexercisewillbeachallengeinsuch

people. Such a program wouldrequirepeople toalso exerciseon

their own, wherebadexercise habits canflourish.On theotherhand, motivated patients with PD randomized to the control

group mayrecognizepotential exercisebenefits andengage on

their own. Moreover, sucha controlledstudy of PD progression

would necessarilyrequire prolongedfollow-up (eg,a fewyears),

andtheexpected dropoutratewouldcompromiseinterpretation.

Realistically, perhapsthe bestwe can do is baseour PD exercise

recommendations on the existing published literature.

To summarize, first, current physical/occupation therapy

referralsfor those with PD shouldbe for specificproblemsthat

arelikely to benefit. Second, physical therapypractices should

beginto incorporate facilitationof ongoing aerobic exercise and

fitness.

Relatedarticle page 291

Editorial Opinion

jamaneurology.com (Reprinted) JAMANeurology March 2016 Volume 73, Number 3 269


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ARTICLE INFORMATION

AuthorAffiliation: Department of Neurology,

MayoClinic, Rochester, Minnesota.

Corresponding Author: J.Eric Ahlskog, PhD, MD,

MayoClinic, Department of Neurology, Gonda8,

Rochester,MN 55905 ([email protected]).

Published Online: January 19,2016.

doi:10.1001/jamaneurol.2015.4449.

Conflict of Interest Disclosures:Nonereported.

REFERENCES

1. ClarkeCE, Patel S,Ives N, et al.Physiotherapy

andoccupationaltherapy vs no therapy in mild to

moderate Parkinsondisease: a randomizedclinical

trial [published online January 19,2016]. JAMA

Neurol . doi:10.1001/jamaneurol.2015.4452.

2. Ahlskog JE.Does vigorous exercisehavea

neuroprotective effect in Parkinsondisease?

Neurology . 2011;77(3):288-294.

3. Ahlskog JE.Cheaper, simpler, andbetter: tipsfor

treating seniors with Parkinsondisease.Mayo Clin

Proc . 2011;86(12):1211-1216.

Implementing Recommendations

for Depression Screeningof Adults

HowCanNeurology Contribute to the Dialogue?Helen S. Mayberg, MD

TheUSPreventiveServicesTaskForce(USPSTF)hasofferedits

updated recommendations for the screening for depression in

adults. Thedocument, publishedthis week in JAMA, updates

a review ofthe evidence as tothe net benefit ofaccurate

diagnosis,effectivetreatment,

and appropriate follow-up af-

ter depression screening for

adults older than years,

including pregnant and postpartum women, complementing

previousrecommendations fordepression screeningin children

and adolescents (http://www.uspreventiveservicetaskforce

.org). There is no question that primary care screeningoffers a

first-line medical opportunity to identify patients with an

undiagnosed major depressive episode. Use of standardized

screening instruments and evidence-based treatments are a

critical first step. Thatsaid, an unsettlingrealityremains:how,

even with improved efficiency of screening and more timely

diagnoses, do we secure the necessaryresourcesto ensure that

depressed patients not only receive treatment and follow-up,

but that the tre atm ent selected is bot h appropri ate and

optimized for the individual. Compounding these challenges,

neurological patients with depression, even when identified,

maybe reticent toacceptpsychiatrictreatment,andlikeinternal

medicine and primary care, the time and resources needed to

address the behavioral “symptoms” are often eclipsed by core

demands of the principal neurological or medical condition.For a patient presenting with major depressive episode, an

antidepressant medication or evidence-based psycho-

therapyis currently recommendedas first-line treatment, with

remissionratesto these options roughly equivalentin allpa-

tients except the mostseverely ill.With thisperceivedequiva-

lency, treatmentselection is oftenbasedon factors such as pa-

tient and health care professional preference, cost and

accessibility, and potential adverse effects. However, the odds

are actually against remission in patients currently treated

using this approach. At best, % of patients achieve remis-

sion with a first treatment, and the “wrong” first choice has

significantindividual andsocietal costs due to continued dis-

tress, risk of suicide, loss of productivity, and wasted re-sources associated with to months of an ineffective treat-

ment. Moreover, among theroughly %to %of depressed

patients who do not remit with their first treatment, many do

not return to explore other options, with potential lethal

consequences.These sameconcernshold fordepression pre-

senting in patients with neurological diseases and othermedi-

cal illnesses where the combined presence of a mood disor-

der has a magnified effect on disability.

Clearly, treatments are highly effective in some individu-

als, but there is no reliable way to match patients to their best

treatment option or to avoid those that are unlikely to be ef-

fective, even in the setting of equal access. Developing reli-

able biomarkers that can stratify individual patients to spe-

cific treatments is essential to achieve the goal of a more

personalized level of care forpatients withdepressionand all

neuropsychiatric disorders.Manymedical specialtiessuch as

those treating heart diseaseand cancer nowroutinely use pa-

tient-level biological measures to subtype and stratify pa-

tients to treatments, andto guide treatmentmodificationswith

disease progression or categories of disease risk, substan-

tially improving patient outcomes.

Toward a “precision medicine” approach for depres-

sion, various strategies have been tested, including clinical,

imaging, genetic, electroencephalographic, and immuno-

logical metrics, but with limited clinical impact thus far.Motivated to translate ongoing advances in functional and

structural neuroimaging methods and mounting evidence

of () distinct patterns of brain dysfunction across clinically

defined depression subgroups, () regional correlates of spe-

cific mood, motor, and cognitive syndrome dimensions, and

() differential change patterns with mechanistically dis-

tinct treatments, investigations of brain-based biomarkers

that predict treatment outcomes to standard first-line treat-

ments have been initiated. Recent studies have identified

some initial promising imaging biomarker candidates that

predict remission and nonresponse to cognitive behavioral

therapy or a standard selective serotonin reuptake inhibitor

Relatedarticle at jama.com

Opinion Editorial

270 JAMANeurology March2016 Volume 73,Number 3 (Reprinted) jamaneurology.com


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new and appropriate goals for parkinson disease physical therapy

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