Read Full Text: Diagnosis and Treatment of Parkinson Disease: A Review (This is a paid article, but we still thought it was important to cover.)
Journal: JAMA - Journal of the American Medical Association
Year Published: 2020
Ranked 2nd on our list of the 100 Most Influential OT Research Articles
CEU Podcast: Parkinson’s Disease Evidence Review with Brandy Archie (CE Course)
The mention of OT in this week’s article is tiny—but it’s powerful.
We’re reviewing a prestigious guideline on Parkinson’s disease (PD) treatment. The authors recommend that rehab therapies begin upon initial diagnosis of PD, continuing across the course of the disease.
Sadly, as a profession, we are under-serving clients with PD. Rehab isn’t always delivered as consistently to these patients as the research recommends.
By specifically understanding how we can help patients with PD, you will be able to confidently advocate for our role in their care. This article really delivers that knowledge, covering key information about the PD disease process, the pervasiveness of non-motor symptoms, and the effectiveness of different treatments.
This updated information about PD should definitely impact how you plan your sessions. (Hint: please be talking about exercise!) It should also push us to consider new care models for all of our patients with chronic conditions.
Let’s dive in.
Introduction to Parkinson’s disease
Neurological conditions are the leading cause of disability worldwide. And, for unknown reasons Parkinson disease diagnoses are increasing more rapidly than other disorders.
An estimated 6.1 MILLION people around the world had a Parkinson disease diagnosis in 2016. This was 2.4x higher than in 1990—that’s a huge increase.
Most of the time, the cause of PD is unknown. But, there are known genetic and environmental contributors. In some studies, exposure to the following are linked to an increased risk of Parkinson disease:
- Pesticides
- Herbicides
- Heavy Metals
Parkinson’s disease is one type of parkinsonism
Parkinsonism is an umbrella category of neurologic disorders characterized by rigidity, slowness, and tremor.
Parkinson’s disease is the most common parkinsonism, but if you work with PD patients regularly (or have someone who doesn’t seem to fully fit their PD diagnosis) these other types of parkinsonism are important to be aware of:
- Multiple system atrophy (We reviewed a very helpful article on this diagnosis!)
- Progressive supranuclear palsy
- Drug-induced parkinsonism
- Vascular parkinsonism
What was the intent of this article?
The authors sought to review the evidence on the diagnosis and treatment of Parkinson’s disease.
This article was published in one of the leading medical journals, JAMA—making it a leading paper on the subject! (It was #2 on our list of the 100 most influential OT-related journal articles.
What were their methods?
The authors searched for systematic reviews and guidelines regarding the diagnosis and treatment of PD.
What did they find?
26 articles met their criteria. Here’s the high points for OTs from their findings:
Pathophysiology (The changes in your body functions)
PD is characterized by the death of neurons that synthesize dopamine.
These neurons are thought to help control various functions in the body. These functions include voluntary movement and a broad array of behavioral processes such as mood, reward, addiction, and stress.
Another hallmark of PD is the presence of Lewy bodies, which are essentially buildups of protein that disrupt normal brain function. (I found this reading on Lewy Bodies, Dementia, and Parkinson’s Disease to be helpful!)
Also important for OTs to note is that the following neurotransmitter systems are also disrupted in Parkinson’s disease:
- Serotonin (think: sleeping, eating, and digesting)
- Norepinephrine (think: blood pressure and heart rate, especially related to fight or flight)
No wonder our patients have such a complex presentation.
How does Parkinson’s progress?
You’ll see in the subtypes below that there is a wide variation in how quickly the disease progresses, and which symptoms are most prominent.
But, there is a typical arch to Parkinson’s disease, which begins with non-motor symptoms.
The Braak hypothesis is the most common way of understanding how the disease spreads. Here are the stages of the hypothesis:
Stages 1&2: The disease begins in the lower brainstem, in the medulla and olfactory bulb. (Hence the decrease in smell and sleeping difficulties.)
Stages 3&4: Midbrain and forebrain structures are impacted and the classic symptoms of PD emerge.
Stages 5&6: Disease progresses throughout the brain and cognitive impairment and hallucinations occur.
Clinical presentation and symptoms for OTs to recognize
You’re likely already familiar with the classic motor symptoms of PD:
- Tremor
- Stiffness
- Slowness
- Imbalance
But, as you probably picked up in the previous sections, the impact of PD reaches far beyond motor symptoms.
The article specifically notes that patients may not volunteer non-motor symptoms, because they may feel embarrassed by them, or simply be unaware that such symptoms are related to PD.
Non-motor symptoms may begin to develop years before the classic motor symptoms of PD emerge. Non-motor symptoms tend to increase in severity over the course of the disease.
These prodromal symptoms include:
- Rapid eye movement sleep disorder (This is even more difficult than it sounds, as patients tend to literally act out their dreams.)
- Loss of smell/hyposmia
- Autonomic dysfunction
- Constipation
- Urinary dysfunction
- Orthostatic hypotension
- Excessive daytime sleepiness
- Depression
As the disease progresses, the following symptoms also appear in many patients.
(%) indicates approximate percentage of patients that experience the symptoms:
- Visual disturbances (22-78%)
- Somatosensory dysfunction and pain (30-85%)
- Anxiety (60%)
- Apathy (60%)
- Psychosis, usually in the later stages (40%)
- Dementia (40% at 10 years, 83% at 20 years)
Subtypes of Parkinson’s disease
If you’re like me, you can think of your own community and patients, and you’ll recognize that PD presents in many different ways. It also progresses at different speeds in different people.
There is an ongoing attempt to categorize different subtypes of PD, and here’s the best understanding we have at this time:
-
Mild motor predominant (49-53%): Younger age of onset; mild motor and non-motor symptoms; slow progression; good medication response.
-
Intermediate (35-39%): Intermediate age of onset and symptoms; moderate-to-good response to medications.
-
Diffuse malignant (9-16%): Symptoms progress rapidly; baseline motor symptoms are accompanied by rapid eye movement sleep behavior disorder, mild cognitive impairment, and orthostatic hypotension; worse response to levodopa (medication for PD)
Diagnosis and Assessment
Diagnosis of Parkinson disease for the most part is made by history and examination.
There is a test called “DaT SPECT” that measures dopamine transporters that can help confirm the diagnosis—though this option is typically only used if the diagnosis is uncertain. (Especially in the early stages it can be difficult to differentiate between the similar diagnosis we mentioned earlier in the article.)
Relevant to OTs, the two assessments that were mentioned related to treatment were the same we have seen in other articles:
Parkinson’s Disease Questionnaire - 39 (PDQ-39)
Unified Parkinson’s Disease Rating Scale (UPDRS)
The PDQ-39 is free, easy to administer and helps ensure you are addressing PD holistically!
See all Parkinson’s Assessments
Treatment
For all PD patients, treatment is currently geared toward addressing symptoms.
There are medications that bring significant relief from symptoms—but, ultimately, these do not modify the overall course of the disease.
The most promising treatment that shows the possibility of actually slowing the progression of the disease is high-intensity exercise, which we’ll discuss below.
Let’s look at some more details about what the article says about OT-related treatment:
Rehab should begin at diagnosis and be continued throughout the disease course.
In a Q&A section of the article the authors answer this question:
Q: How soon should rehab therapies be prescribed after a patient is diagnosed with Parkinson’s disease.
The authors answer: “At the time of diagnosis, an appropriate exercise regimen can be prescribed based on the patient’s symptoms. Rehabilitative therapies should be continued through the disease course."
The article notes that occupational therapy is part of the interdisciplinary therapy team vital to providing quality care for PD patients.
Rehabilitative therapy is listed as an option for all symptoms across all disease stages. Alongside our rehab colleagues, the overall goals are to improve:
- Motor symptoms
- Gait and balance
- Function
- Hypophonia
- Dysphagia
Please, don’t neglect exercise
Exercise is a key intervention for addressing the motor symptoms of PD. The article lists it as an intervention for all stages of the disease (and as a way to address all types of motor symptoms).
The authors do not connect exercise directly to OT intervention, but I am going to make the leap to say that, alongside others on the care team, you should definitely focus on helping your patients establish a realistic exercise routine.
The article lists these as effective exercise interventions:
- Gait and balance training
- Progressive resistance training
- Treadmill exercise
- Strength training
- Aerobic exercise
- Music and dance-based approaches
- Tai chi
There clearly is not one right type of exercise. As a therapist, you have the opportunity to listen to your patients and find the right exercise habit(s) they can continue to follow, long after their time with you ends.
This resources also was not mentioned in the article, but I love it as a resource to address exercise:
Non-motor symptoms
For the many non-motor symptoms listed earlier in the article, the authors state that symptomatic treatment is similar to what you’d deliver to any member of the general population with those same symptoms. The article does not mention OT in this section, but I’ll share some thoughts on this in my final takeaways.
A final note on medication management
If you want to dive deeper into medication management, there is a lot of great information on medications covered in this article.
One side effect I thought OT should be aware of is dyskinesia (involuntary writing- or dance-like movements). When dyskinesia begins to interfere with function, it may be time for a medication adjustment or perhaps a more advanced treatment approach.
Takeaways for OT practitioners
(These were my own personal takeaways and were not mentioned directly in the article.)
1. Help your PD patients build a habit of exercise.
As an OT, you may not think of yourself as an exercise coach—but you are certainly an expert in helping people build habits and routines. And, this is exactly what these patients need from you. They need someone to listen to their unique situations and coach them to find exercise routines that they can sustain after therapy ends.
I highly recommend this new 2022 article to see the latest on our understanding of the neuroprotective effects of exercise.
Here’s the overall takeaway:
“In the long term, the maintenance of high regular physical activity levels and exercise habits was robustly associated with better clinical course of PD, with each type of physical activity having different effects.”
2. Plan to see patients throughout the disease course.
I really appreciated how this article listed occupational therapy as a treatment option throughout the disease course.
In any chronic degenerative condition, a patient’s functional status and occupational profile is going to change over the years. For that reason, it might be best to think of yourself as a long-term consultant. Encourage your patients to seek therapy again when their status changes. Even if it is just for a few visits, you can make a difference. You can help them with their changing functional status and check in on the exercise routine you helped them establish!
3. There seems to be a massive need to help address non-motor symptoms—and this is a need you may be able to help meet.
While motor symptoms are the most visible sign of Parkinson’s disease, they are not necessarily the most debilitating. As OTs, we know how much things like urinary dysfunction, mood, and hypotension can impact your day (and your relationships).
You may be the first professional to talk with your patients about non-motor symptoms and normalize this experience for them and their families. So, do not shy away from these conversations.
The article discusses medication management for many of the non-motor symptoms. And, also in therapy we seem to be growing in our ability to help patients navigate things like autonomic dysfunction. I’ll be super curious to hear if any of you address non-motor symptoms in your treatment of PD!
Here’s the full APA citation for this article:
Armstrong MJ, Okun MS. Diagnosis and Treatment of Parkinson Disease: A Review. JAMA. 2020;323(6):548–560. doi:10.1001/jama.2019.22360
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Brandy Archie. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!