We are doing physical therapy wrong in Parkinson's: randomizing burst vs. spaced approaches
KELVIN AU, MD A FORMER FELLOW AT THE NORMAN FIXEL INSTITUTE FOR NEUROLOGICAL DISEASES AND NOW FACULTY AT THE UNIVERSITY OF KANSAS DEPARTMENT OF NEUROLOGY.
HTTPS://PUBMED.NCBI.NLM.NIH.GOV/35325665/
Most persons with PD (PWP) will, during their disease course, report difficulties with balance, posture, stance, transferring, walking and physical function.
Physical therapy (PT) is beneficial not only to address select PD motor symptoms but can be helpful in maintenance of function.
We should be thinking more about the importance of maintaining function. Maintaining function should be a critical goal in PD treatment.
PT is most commonly prescribed adjunct to PD medication management.
There is no standardized approach for PT delivery.
Intensive inpatient rehabilitation strategies over 4-8 weeks have been shown to be beneficial in the short term.
Inpatient care is frequently not accessible, practical or affordable.
Following a burst of PT for PD, most clinicians report symptom recurrence.
In this week’s blog post we will review the new paper by Au et. al. which randomized persons with PD to either burst or spaced physical therapy.
What has driven the use of “burst physical
therapy”?
A “burst” strategy has been driven by both the reimbursement structure (e.g. USA Medicare) and by the use of burst therapy for other neurological diseases. Burst therapy has been commonly used post-stroke and post traumatic brain injury. A “burst” simply refers to the idea that we prescribe an intense short course of therapy and then declare victory by discontinuing the therapy and asking the person to reintegrate back into society. This strategy may not be optimal in PD.
Why use a “spaced rather than a burst
approach in Parkinson’s?
A burst approach may be a suboptimal PT strategy for PD. Why? It has to do with the circuitry involved in Parkinson’s (e.g. the basal ganglia) and that Parkinson’s is a disease of “cueing.” It makes sense that long-term continuous PT will be associated with positive outcomes, however a long-term spaced PT paradigm was, until the current study, not tested in a randomized fashion.
How did the Au et. al. study address the
question of burst vs. spaced physical therapy
for Parkinson’s disease?
The burst PT was defined as 2 PT visits per week for 6 weeks (12 sessions) and the spaced PT as 1 PT visit every other week for 6 months (also equivalent to 12 sessions).
It was hypothesized that spaced PT would have a better maintenance effect when compared to conventional burst PT.
The study was designed to inform on the optimal timing for PD PT and to provide critical information on safety, feasibility and outcome measures for a future larger comparative effectiveness study.
THE STUDY DESIGN. HTTPS://PUBMED.NCBI.NLM.NIH.GOV/35325665/
Which group (spaced vs. burst) was better at
“maintaining” baseline Parkinson’s symptoms?
There was a failure of the burst PD intervention group to maintain timed up and go (TUG) scores when followed for a period of 6 months.
The spaced PT group maintained TUG benefit for the duration of the 6 month study.
The main difference between groups was that the burst group did not receive regularly scheduled PT following 6 weeks of therapy.
The burst group received the same total number of PT sessions as the spaced group.
The differences revealed strongly suggest that the timing of PT sessions may be important to maintain benefit and to prevent decline.
How should payor systems like Medicare be
changed for persons with Parkinson’s?
Every payor system around the world is different. In the US (as one example), the most common way to receive physical therapy is through a prescription from your doctor. The dollar amount that can be justified is $2110/year; if you are on Medicare. Payment and extensions depend on continuous improvement and NOT ON Maintenance. Unless we change our thinking, we are by using bursts of therapy doing it wrong; instead of aiming for maintenance of effect.
Similarly, insurance companies and governments around the globe frequently limit physical therapy coverage, emphasize bursts and continue therapy only if improving. Also, many participants in insurance programs have deductibles, co-insurance and copayments which may impact continuation or access to therapy. Ouch!