Are we writing our prescriptions for Parkinson's disease physical therapy wrong?
This is the paradigm tested in the recent randomized trial in Parkinsonism and Related Disorders and in a followup Viewpoint that appeared in JAMA Neurology.
Parkinson’s disease (PD) folks face increasing mobility deficits, including difficulties with transfers, posture, balance and walking. Too often they are seen by a doctor who simply writes a prescription for 6-8 weeks of ‘physical therapy.’ A burst of acute, closely spaced visits may be appropriate for stroke and back pain; not so much for PD. A recent randomized clinical trial addressed this issue in Parkinsonism and Related Disorders and a follow-up Viewpoint was published in JAMA Neurology. We will review the key concepts in this week’s parkinsonsecrets.com blog.
Why is the timing of Parkinson’s PT important?
We are over-concerned with accessing the service than with the timing-based delivery patterns of PT.
These can vary by frequency, duration, intensity, and the experience of the therapist.
There continues to be no consensus on optimal timing in PD.
PD is a chronic progressive disorder and we know from experience when we stop therapies folks get worse.
Why not ‘spread out’ the therapy over time?
Can bursts of therapy help Parkinson’s folks?
Absolutely. PD outcomes improve with acute time-limited intensive PT that spans 4-8 weeks in duration (i.e., burst PT). Whether benefits are sustained is another open question.
What was the most recent trial of spaced vs. burst therapy in Parkinson all about?
It was a small, randomized trial (n=30 folks) showing that spaced PT for PD outperformed a burst approach.
Participants received burst therapy, comprised of two PT sessions weekly for 6 weeks, or spaced therapy, which consisted of one PT session every 2 weeks for 6 months.
The primary outcome measure was the validated Timed Up and Go (TUG) test which was recorded at 6 months.
Both groups were allowed to exercise.
What were the results of the trial?
Both spaced and burst approaches were safe, feasible and effective.
Only spaced PT however, maintained its effect at the 6-month interval,
The burst group had a significant decline at 6 months.
What should we be thinking about when prescribing physical therapy for Parkinson’s disease?
We need larger, longer duration studies conducted with more diverse participants drawn from a variety of healthcare settings.
Future comparative effectiveness studies should consider hybrid effectiveness-implementation trial designs. Hybrid trials facilitate the evaluation of implementation outcomes alongside clinical effectiveness in an effort to elucidate the impact of therapy in real world settings, and to facilitate more rapid translation of clinical innovations.
In the meantime we should keep in mind that ‘spreading out’ or ‘spacing physical therapy’ likely has a benefit in a disease such as Parkinson’s.
We will need to assess whether spaced PT will also reduce falls, fractures and cost to any health system implementing this approach.
Tell your doctor to write your prescription for physical therapy in Parkinson’s disease as time based and not burst therapy.
The parkinsonsecrets.com blog content is provided by Dr. Michael Okun and Dr. Indu Subramanian.
The parkinsonsecrets.com website artist is Dr. Jonny Acheson.
Selected references:
Salloum RG, Au KLK, Okun MS. Timing of Physical Therapy Sessions for Individuals With Parkinson Disease May Unlock Benefits. JAMA Neurol. 2022 Sep 12. doi: 10.1001/jamaneurol.2022.2649. Epub ahead of print. PMID: 36094521.
Au KLK, Lopes JLMLJ, Kraus A, Patton K, Warren L, Gao H, Wong JK, Moore K, Toledo JB, Stiep T, Frey J, Tholanikunnel T, Hess C, Almeida L, Ramirez-Zamora A, Okun MS. A randomized clinical trial of burst vs. spaced physical therapy for Parkinsons disease. Parkinsonism Relat Disord. 2022 Apr;97:57-62. doi: 10.1016/j.parkreldis.2022.02.021. Epub 2022 Mar 10. PMID: 35325665.