Read Full Text: Physiotherapy and Occupational Therapy vs No Therapy in mild to moderate Parkinson disease (Free to access, but must create a JAMA account)
Journal: JAMA Neurology (2018 Impact Factor 12.3)
Year Published: 2016
Ranked 42nd on our 2014-2019 list of the 50 most influential articles
Parkinson’s Disease (PD) is our most-discussed diagnosis in the Club, so far. PD therapy is a hot topic right now because there is so much promise behind exercise-based neuroplasticity.
But, this week’s article takes a look at the age old question:
Is any therapy better than no therapy?
The answer appears to be: probably not.
In this large-scale randomized control trial, we find that patients with mild-to-moderate PD did not show immediate or medium-term benefits from low-dose, patient-centered, goal-directed OT and PT.
We have a lot to learn from this article.
First, it pushes us to make sure we are delivering evidence-based treatments to our clients.
Secondly, it drives home the fact that the verbiage many of us use to justify treatments— “Patient demonstrates functional deficits and therefore needs OT”—is not enough. Writing a line like that simply isn’t convincing, especially when physicians are reading articles like this one.
What population did this research include?
The study included 762 patients with mild-to-moderate PD. Mean age was 70 years.
The patients were recruited from 38 sites across the UK. All patients had self- or caregiver-reported limitations in ADLs.
How was OT/PT utilized in this study?
Patients were randomly assigned to the “PT and OT therapy” group or the “no therapy” group (the control group).
PT and OT were delivered in the community or outpatient setting. Before the trial, a framework for therapy content was developed and agreed upon by expert therapist work groups.
After initial assessments by therapists, therapy was tailored to the individual patient using a patient-centered, joint goal-setting approach.
What did the actual therapy programs look like?
The median number of sessions (of OT and PT combined) was 4.
The mean time per session was 58 minutes.
And the mean duration of therapy programs was 8 weeks.
Occupational therapy logs showed that the most frequent interventions were for:
- Transfers
- Dressing and grooming
- Sleep and fatigue
- Indoor mobility
- Household tasks
- Other environmental issues
The authors make a point of noting what was NOT included in the sessions.
- Only 3 PTs provided PD-specific exercises. There was no formal exercise progression protocol for any patient.
- The interventions from OT were focused on equipment provision, onward referral, and other advice. There was little task-related practice.
What assessments were used?
Primary:
Secondary:
What were the results?
There was definitely some complexity and nuance to the results. For example, even though patients did not show any clinically significant improvement on the NEADL, there was borderline significance in favor of therapy on the EuroQol.
But, overall, the outcomes were pretty grim, which led the authors to conclude:
This evidence does not support the use of low-dose, goal-directed PT and OT in the early stages of PD.
Takeaways for OT practitioners
(These are my personal takeaways, and were not mentioned in the article.)
1. We should probably stop insisting that “any therapy is better than no therapy.”
As therapists, we need to recognize that we probably have a bias as to the efficacy of the therapy we are providing.
This bias can lead us to believe that all of the therapy we provide is beneficial—especially if it is patient-centered and goal-oriented.
But, in reality—like all health professions—we have historically provided treatment that probably did not benefit our patients in the ways we would have hoped.
The good news is that when have the courage to recognize this, it can push us to needed innovation. For one such story, I recommend this TED Talk.
2. You could feel the authors’ shock about the kind of therapy that was being delivered.
I may be reading into the dry journal-style writing a bit, but from what I can gather, the authors were shocked at the therapy being provided.
Or, more importantly, what wasn’t provided.
I felt like they went out of their way to drive home the serious lack of focus on exercise. The guidelines we looked at previously told us that exercise should be the foundation of all Parkinson’s Disease therapy because of the promise of exercise-based neuroplasticity.
And, as to the OT provided (the most-used interventions all put the patient in a passive role—which is a terrible posture to be in for behavior change. As they mentioned, there was little actual practice (and, therefore, there was little active learning) that was happening in the therapy sessions.
Patient-centered goals alone are simply not sufficient—especially if we are not setting our clients up to actually modify their habits and behavior.
3. When justifying why therapy is needed, we need to get specific.
It’s good to note that this article appeared in the Journal of the American Medical Association: Neurology, so the intended audience is neurologists (and probably some general practice doctors). If they are reading this research, it is really up to us to get specific about the new evidence that has emerged, and what we can do differently to help their patients.
It is also good to consider that payers may also be weighing evidence like this when it comes to reimbursements. So, it is really important to get specific about the type of therapy we are providing. “Needs therapy for functional deficits” might be accurate, but we need to specify the type of therapy we intend to deliver—and why that therapy will likely help our patients.
Listen to my takeaways in podcast form:
(Possibly) Earn CEUs/PDUs for reading this article
Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Clarke, C., Walker, M., Sackley, C., Patel, S., Ives, N., Dowling, F. and Woolley, R. (2016). Physiotherapy and Occupational Therapy and Mild to Moderate Parkinson’s Disease. JAMA Neurology, 73(7), p.894.