Several troubling headlines appeared recently after a large randomized controlled study, published in the American Medical Association’s neurology journal (JAMA Neurology), concluded that physical therapy (PT) and occupational therapy (OT) did not improve activities of daily living in people with Parkinson’s disease (PD). “Millions of pounds wasted providing physiotherapy for Parkinson’s” and “Parkinson’s patients may not benefit from physical therapy” were headlines from The Telegraph and United Press International. However, I strongly caution the Parkinson’s community not to accept these findings as indicating that therapy services don’t help.
The study compared 381 people with mild to moderate PD who participated in PT and/or OT to 381 people who did not. PT and OT were delivered based on UK guidelines. Individuals in the study received an average of 4 visits of PT and/or OT (range 1-21 visits) over 8 weeks. In their PT and OT, study participants did many types of training activities, such as walking, general conditioning, posture training, dressing, or other household tasks. They also may have been treated for sleep and fatigue complaints. Researchers drew their conclusions because there was no significant difference between groups on a questionnaire about how participants performed routine daily activities at 3 and 15 months. There did appear to be a small benefit of PT/OT at 3 months on a generic quality of life measure, and a small benefit of PT/OT at 15 months on a PD-specific quality of life measure.
I find the results and conclusions unconvincing and recommend that neurologists should not change their practice based on them, especially in the US. First, the authors acknowledge that the PT and OT were delivered with a very “low dose.” The American Physical Therapy Association agreed that PT/OT are usually performed with “larger doses” in the US than in this study. The number of PT/OT visits recommended in US clinics is based on the individual’s goals, problems, and current/past experiences. The number of PT/OT visits recommended or completed may also depend on different types of insurance coverage. Second, most of the study participants had only mild or moderate PD. Often, we deliver PT in early PD to help patients prepare for changes that come with advanced PD. Thus, benefits may not be seen for several years. Based on the study’s limitations, I think a more appropriate headline would be: “Physical and occupational therapy research prompts questions about traditional healthcare delivery.”
The results of this study may be due to the differences between how PT, OT, related education, and exercise are performed in standard healthcare settings and what is done in research studies. In the past, clinical PT/OT were recommended most frequently for people with moderate to advanced PD, when balance problems could limit household activities and community participation. However, PT-related exercise has been shown to be effective for people with mild to moderate PD when it is delivered more frequently and intensely (2-4 sessions per week for 4 weeks to 2 years). More research is needed to determine (1) which interventions can be delivered effectively in clinical PT and OT, (2) when to deliver them, (3) to whom they should be delivered, and (4) how improvements should be measured.
To try to answer some of these questions, I looked at the data collected in the Parkinson's Foundation Parkinson’s Outcomes Project. The figure to the right shows the percent of patients who are referred to PT and OT at each of the Parkinson’s Outcomes Project sites and at each stage of PD. As you can see, referral rates vary a lot between centers. This variability indicates that PT and OT may be approached differently at different Parkinson's Foundation centers, and we need to learn why. The Parkinson's Foundation is currently assisting researchers to study these questions, as well as how PT and OT are related to outcomes. I hope that this research will lead to improved PT and OT delivery for all people with PD.
Miriam Rafferty is a physical therapist at the Rehabilitation Institute of Chicago and a postdoctoral research fellow in Health Services and Outcomes Research at Northwestern University. She has assisted the Parkinson's Foundation with portions of the Parkinson’s Outcomes Project research since 2014.