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Physical and occupational therapy have long been components of Parkinson disease (PD) treatment. Prior to the advent of levodopa, this was a primary therapeutic modality.
What is the current role for physical therapy in PD? Should everyone 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
relevant consideration in the context of its single-payer National
Health Service. The cost-effectiveness of routine referral of patients with earlier-stage PD for physiotherapy and occupational
therapy was addressed in an
article in this edition of JAMA
Neurology.1 Half of more than
Related article page 291
700 patients with PD from
across the United Kingdom were randomized to standard practice physiotherapy and occupational therapy (median, 4; hourlong therapy sessions). Compared with the control group, this
therapy intervention failed to meaningfully influence the activities of daily living or quality-of-life measures, with follow-up at
3 and up to 15 months. The investigators concluded that, This
evidence does not support the use of low-dose, patient-centered,
goal-directed physiotherapy and occupational therapy in patients
in the early stages of PD.1 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 moderate PD and the enrollment criteria excluded patients whose
clinicians believed needed physical/occupational therapy.
Thus, one may conclude from this investigation that blanket
referrals of all patients with earlier-stage PD for routine physical or occupation therapy appears to be cost-ineffective.
Intuitively, certain PD-related symptoms should benefit from
routine physical therapy strategies, including problems such as
gait freezing, imbalance/fall risk, or immobilized limbs. Patients
with PD with shortened stride or reduced arm swing benefit from
strategies for consciously increasing attenuated movements. Such
circumscribed problems were not the focus of this investigation.
The therapy schemes performed in this investigation are
also notable: Physiotherapy and [occupational therapy] were
deliveredby qualified therapists working within the National Health Service (NHS) per local practice. Such routine
physical therapy practices are universally established and have
been used for decades in treating PD. Per convention, these primarily focus on stretching, balance, posture, gait, and strategies for facilitating activities of daily living. More recently, protocols for enhancing movement amplitudes have been added
(eg, consciously focusing on increasing stride length and arm
movements). However, these conventional physical therapy
practices take no advantage of what has now become increasingly apparent: ongoing aerobic exercise may slow the progression of PD.2 To date, it has not been part of physical therapists job description to facilitate ongoing aerobic exercise.
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Opinion Editorial
ARTICLE INFORMATION
REFERENCES
Implementing Recommendations
for Depression Screening of Adults
How Can Neurology Contribute to the Dialogue?
Helen S. Mayberg, MD
tress, risk of suicide, loss of productivity, and wasted resources associated with 2 to 3 months of an ineffective treatment. Moreover, among the roughly 60% to 70% of depressed
patients who do not remit with their first treatment, many do
not return to explore other options, with potential lethal
consequences.4 These same concerns hold for depression presenting in patients with neurological diseases and other medical illnesses where the combined presence of a mood disorder has a magnified effect on disability.5
Clearly, treatments are highly effective in some individuals, but there is no reliable way to match patients to their best
treatment option or to avoid those that are unlikely to be effective, even in the setting of equal access. Developing reliable biomarkers that can stratify individual patients to specific treatments is essential to achieve the goal of a more
personalized level of care for patients with depression and all
neuropsychiatric disorders.6 Many medical specialties such as
those treating heart disease and cancer now routinely use patient-level biological measures to subtype and stratify patients to treatments, and to guide treatment modifications with
disease progression or categories of disease risk, substantially improving patient outcomes.
Toward a precision medicine approach for depression, various strategies have been tested, including clinical,
imaging, genetic, electroencephalographic, and immunological metrics, but with limited clinical impact thus far.
Motivated to translate ongoing advances in functional and
structural neuroimaging methods and mounting evidence
of (1) distinct patterns of brain dysfunction across clinically
defined depression subgroups, (2) regional correlates of specific mood, motor, and cognitive syndrome dimensions, and
(3) differential change patterns with mechanistically distinct treatments,7 investigations of brain-based biomarkers
that predict treatment outcomes to standard first-line treatments 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
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