Multidisciplinary treatment of Parkinson s disease: current state and future directions

Transcription

1 Review Multidiscipliary treatmet of Parkiso s disease: curret state ad future directios Sotirios A Parashos* Practice Poits The multidiscipliary treatmet is a promisig yet poorly studied therapeutic approach i Parkiso s disease. Implemetatio of this approach i cliical practice ad i future research eeds to take ito accout the followig cosideratios: target eed, assessmet tools ad outcome measures, therapeutic itervetios, iterdiscipliary implemetatio, settig (ipatiet vs outpatiet) ad follow-up. There is good evidece i literature to support the use of physical, occupatioal ad speech therapy ad ursig services i Parkiso s disease. The multidiscipliary treatmet of Parkiso s disease has bee used i the cliical settig for a umber of years i order to address Parkiso s disease-related symptoms that do ot usually respod to the established pharmacological treatmets, but also to mitigate impairmet, decrease disability ad ehace quality of life. Yet, there are very few studies o the effectiveess of such treatmet. This article discusses the existig evidece ad proposes approaches for the cliical applicatio ad future research of the multidiscipliary treatmet of Parkiso s disease. Cosideratios i desigig a cliical program or a cliical trial should iclude a target eed; selectio of the appropriate assessmet tools ad outcome measures; selectio of appropriate itervetios; iterdiscipliary implemetatio; ipatiet versus outpatiet settig; ad follow-up plaig. Summary Parkiso s disease (PD) is a chroic, progressive degeerative disease of the ervous system. The disease affects approximately seve out of every 1000 persos above the age of 40 years ad three out of every 100 persos older tha 80 years ad its icidece icreases dramatically with age [1,2]. Although the pathological hallmark of the disease is the loss of the dopamiergic euros i the pars compacta of the substatia igra, the eurodegeerative process ecompasses most areas of the cetral ad parts of the peripheral ervous system [3]. The advet of l dopa treatmet ad the subsequet developmet of additioal dopamiergic therapies have improved survival amog PD patiets [4], yet this improved survival belies the *Struthers Parkiso s Ceter, 6701 Coutry Club Drive, Golde Valley, MN 55427, USA ad Mieapolis Cliic of Neurology, 3400 West 66th Street, Edia, MN 55434, USA; Tel.: ; Fax: ; sotirios.parashos@mpls-cliic.com /CPR Future Medicie Ltd Cli. Pract. (2012) 9(2), part of ISSN

2 Review Parashos fact that may PD patiets will develop serious complicatios from their disease, which ofte lead to istitutioalizatio [5]. Ideed, several years after disease oset, the cliical picture of PD is domiated by symptoms ot resposive to treatmet with l dopa [6]. This may i fact be the utoward byproduct of the l dopa-mediated prologed survival amog PD patiets [4] : the disease process is give the opportuity to progress further, icreasigly ivolvig structures of the brai with diverse fuctios [3] that bear little relatioship with dopamiergic eurotrasmissio. Such symptoms of advaced PD may iclude o-l dopa-resposive motor symptoms (e.g., postural istability, falls, dysphagia ad dysarthria), cogitive dysfuctio ad demetia, psychiatric sydromes (e.g., psychotic pheomea, depressio, axiety, emotioal lability ad apathy) ad symptoms of autoomic dysfuctio (e.g., hemodyamic istability, gastro itestial motility disturbaces, disordered sphicter cotrol ad sexual dysfuctio). As awareess of the o-l dopa-resposive symptoms icreased, it became evidet that a umber of these problems are preset eve from the earliest stages of the disease [7]. Fuctioal eurosurgery ad pharmaceutical itervetios have alleviated to a degree motor complicatios ad some of the o-l-dopa-resposive symptoms, yet it has become clear that additioal treatmet measures were eeded: over the last decade cliical research has icreasigly focused o the use ad optimizatio of therapy protocols to improve fuctio, decrease disability ad ameliorate quality of life i PD. Such protocols typically ivolve cocerted rehabilitative therapeutic courses of physical, occupatioal ad speech therapies, with urse specialist, social services, ad, at times, metal health professioal support, either i a ambulatory [8,9] or i a ipatiet settig [10]. Cosiderig the variety of symptoms that such treatmets address, as well as the multiplicity of disciplies ivolved ad the available methodologies, it is imperative that both cliical practice ad further research i this area follow a predetermied ratioale, so that cliical results ca be appropriately appreciated ad evidece of high quality ca be obtaied with the least possible ambiguity. I this review we discuss the existig evidece ot so much for its itrisic value as such a goal already served by multiple previous recet reviews but rather 190 Cli. Pract. (2012) 9(2) as a startig poit to develop a strategy for the future, i terms of both cliical practice ad study desig. Existig evidece Ufortuately, very little quality evidece exists to support or discourage the use of a multidiscipliary rehabilitative approach o the treatmet of PD. The causes of such deficiecy lie withi the ature of the itervetio itself. A rigorous evaluatio of multidiscipliary treatmets is subject to the followig limitatios accordig to the UK Natioal Cliical Guidelies for d iagosis ad maagemet of PD [11] : Variatios i locatio of therapy (home, o utpatiet cliic ad i hospital) Lack of reportig the itesity of therapy give Variatios i therapy regime betwee trials Uclear qualificatios ad experiece of p erso deliverig the itervetio Short trial duratio ad lack of log-term follow-up Small sample sizes without power calculatios provided Lack of reportig methods of radomizatio or allocatio cocealmet Lack of reportig drop-outs from trials Lack of itetio-to-treat aa lysis To this list, oe would have to add the methodological limitatios of provig the effectiveess of multidiscipliary treatmets; such studies may ever reach what is curretly the gold stadard for cliical trials, amely the double-blid, placebo -cotrolled desig, as subjects may ot be blided to the treatmet ad placebo (or sham) treatmets may be easily recogized as such by the study participats. Although some of these shortcomigs have bee overcome i more recet trials, there remais a lack of stadardizatio of the therapeutic approach that ot oly limits oe s ability to derive geeralizable coclusios, but also at times results i seemigly cotradictory fidigs. A earlier systematic review of the extat literature o the effectiveess of rehabilitative therapies i PD [12] discovered 44 studies icludig physical therapy (13), occupatioal therapy (4), speech therapy (10), couselig (3), educatioal itervetio (1) ad multidiscipliary (1), all but oe demostratig improvemet

3 Multidiscipliary treatmet of Parkiso s disease: curret state & future directios i at least oe outcome measure. The authors cocluded that such itervetios appear beeficial, addig, however, the caveats of publicatio bias ad ukow cliical sigificace of the reported statistical fidigs. A more recet systematic review [13] focused o the evidece for a multidiscipliary out patiet rehabilitative program for PD ad discovered oly four studies, ragig from poor to good quality, suggestig o log-term beefit to followig a multidiscipliary rehabilitative effort. Cosiderig, however, the quality of the extat evidece, as well as the lack of reliable evidece o the short-term effectiveess of such itervetio, the authors cocluded that further studies were ecessary. Notwithstadig such limitatios, we will edeavor to discuss the existig evidece with regard to specific itervetios, i the cotext of the multidiscipliary model. Elemets of the multidiscipliary model I order to better assess the effectiveess of the multidiscipliary approach, a degree of stadardizatio will be ecessary. Oe problem with the heretofore studies has bee the idiscrimiate iclusio of PD patiets udergoig multi discipliary rehabilitatio, without regard to the particular idicatios, expectatios or goals of the itervetio. Aother problem has bee the appropriateess of the outcome measures for the particular itervetio. Based o the theory supportig the multidiscipliary approach, a schema for stadardizatio, allowig for better assessmet of outcomes, will have to take ito accout the followig cosideratios: Target eed Assessmet tools ad outcome measures Itervetios Iterdiscipliary implemetatio Settig (ipatiet vs outpatiet) Follow-up These elemets ca also be implemeted as criteria i the evaluatio of itervetioal studies assessig the effectiveess of the multidiscipliary model i PD. I the followig sectios, we review these cosideratios. Target eed A multidiscipliary itervetio eeds to fulfill a perceived eed. Followig WHO s Review Iteratioal Classificatio of Fuctioig, Disability ad Health (ICF) model, a target eed may be a impairmet, activity limitatio or loss of participatio level [14]. Some examples are cogitive impairmet, balace impairmet ad fall prevetio, drivig abilities, activities of daily livig, utritio ad weight loss issues ad assessmet for deep brai stimulatio. Idetifyig a targeted eed ot oly helps to select the appropriate assessmet tools ad outcome measures but also allows for better plaig of the appropriate itervetios the disciplies i multidiscipliary ad, moreover, allows for better groupig ad classificatio of differet multidiscipliary protocols, which ca the be idividually studied as to their respective effectiveess. Upo reviewig the existig studies of multidiscipliary itervetios i PD agai [8,13,15], it becomes clear that patiet selectio did ot iclude a requiremet for a perceived eed ad a target of the multidiscipliary itervetio was ot defied, other tha i the form of a outcome measure, usually a health-related quality-of-life measure. The lack of such a declared target i ay of the published studies reders iterpretatio of their results difficult ad may uderpi some of the apparet cotradictios ad icosistecies [13]. Assessmet tools & outcome measures Two types of assessmet tools eed to be etertaied; first, istrumets appropriate for the specific target will eed to be selected, aimed at assessig the patiet at the frot ed. The degree of the specific eed (be that the degree of specific impairmet or disability that eeds to be addressed or the evaluatio of circumstace such as social support system) will eed to be quatified i order to help desig the itervetio ad moitor its progress. A secod type of istrumet eeded would iclude tools to assess the success of the program. As a covetio, for the purposes of this paper, we will use the term assessmet istrumet for the former type ad outcome measure for the latter. Although, theoretically, the same istrumet ca be used for both purposes, i practice, the two types of istrumet will serve somewhat differet purposes ad, therefore, will eed to have somewhat differet characteristics. For example, a assessmet istrumet will eed to have sufficiet resposiveess to chage, so 191

4 Review Parashos that progress ca be moitored ad the itervetio accordigly adjusted. It will have to have sufficiet specificity to the eed targeted ad to PD-specific impairmets. It will have to have excellet test re-test reliability. Sice the purpose of such assessmet istrumets is ultimately to assist i the cliical practice, it may ot be very importat that the istrumet is specific to the particular itervetio to the exclusio of other therapeutic maipulatios (e.g., medicatio chages) that may occur i parallel. O the other had, such a characteristic, however difficult to achieve, would be desirable for a outcome measure, so that the effectiveess of the specific itervetio ca be assessed as much as possible i isolatio from the effects of other factors. At the same time, outcome measures eed ot be specific to the targeted eed aloe, but may explore the effects of the itervetio o other aspects of the disease. By way of example, the success of a itervetio desiged to improve safety with regard to fallig may be assessed with outcome measures of quality of life, caregiver strai, depressio ad axiety. Specific assessmet istrumets ad outcome measures will be discussed with respect to the itervetios later i this paper; however, there are umerous literature sources addressig the appropriateess of such tools [16 19,101]. Similar to developig a ratioal approach i future applicatios of multidiscipliary treatmet, developmet of future assessmet tools ad outcome measures should proceed i a structured ad ratioal maer. I that respect, the priciples embodied withi the ICF model may serve as a blueprit [14]. Itervetios There is o stadardizatio of the disciplies that are ecessary compoets of a multidiscipliary itervetio. It seems logical that the selectio of disciplies will eed to be customized to the targeted eed, allowig for flexibility of iterdiscipliary referrals. Traditioally, multidiscipliary rehabilitatio programs i PD have icluded urse specialists, physical ad occupatioal therapists, ad speech ad laguage pathologist assessmets ad itervetios [8 10]. Disciplies that may also cotribute to the multidiscipliary itervetio iclude dietary specialists, exercise physiologists, metal health professioals, social workers ad eve spiritual couselors ad fiacial advisers. 192 Cli. Pract. (2012) 9(2) Accordigly, medical specialties ivolved may iclude physiatrists, eurologists, eurosurgeos ad psychiatrists. As per good cliical practice, each disciplie will use its ow assessmet istrumets ad will set its ow particular short- ad log-term goals ad develop a strategy. Iterdiscipliary itegratio is oe of the corerstoes of the multidiscipliary model ad is discussed later i this paper; however, it merits special metio here, as goals have to be cross-refereced ad compatible betwee disciplies. Cross-disciplie awareess is a ecessary elemet for the success of this schema ad the ability of the allied health professioals to appreciate ad idetify the eed for a differet disciplie to be ivolved will add cohesiveess ad cosistecy to the itervetio. Therefore, familiarity of the professioals ivolved with the various aspects of PD is importat ad cross-educatio through team reviews of idividual cases is a idispesable step i the whole process. Here, we will review briefly the evidece for the core disciplies of ursig, physical ad occupatioal therapy ad speech ad laguage pathology ad also briefly touch o the remaiig disciplies, for which there may ot be much iformatio i the available literature. Nursig The role of urses i the maagemet of PD has bee extesively studied i the UK, with a particular focus o the cost effectiveess of commuity-based urse specialist services for PD patiets [20 22]. The utility of a PD urse specialist i the settig of a multidiscipliary model has ot bee specifically studied. Nevertheless, a PD specialist urse may fulfill a wide spectrum of patiet eeds withi the multi discipliary model icludig patiet ad family educatio o diagosis [23], symptom maagemet [24], proper use of medicatio [22,25,26], cliical assessmets [27], palliative care [28] ad coordiatio of perioperative care, eurotrasmitter programmig for deep brai stimulatio patiets [29] ad assessmet ad maagemet of omotor symptoms such as issues of sleep [30], cotiece ad costipatio. A urse specialist may also fuctio as the exus of coordiatio for the multidiscipliary team, as well as the liaiso betwee the various allied health professioals, the physicia ad the patiets ad their care parters.

5 Multidiscipliary treatmet of Parkiso s disease: curret state & future directios Physical therapy The beefits of physical therapy itervetios i PD have bee well documeted i the existig literature [31 33]. Because of the wide variety of modalities that have bee studied ad the small size of the studies, the available evidece is cosistet, yet either strog, or very iformative despite its apparet cosistecy. For example, the BIG physical therapy protocol has bee foud to sigificatly improve part III (motor score) of the Uified Parkiso s Disease Ratig Scale (UPDRS) [34], while parallel groups receivig a Nordic walkig program, or traiig i a home exercise program did ot experiece ay improvemets [35]. O the other had, separate studies of Nordic walkig have show improved gait velocity i PD patiets [36] ad of treadmill walkig have show improvemets i objective measures of balace [37,38], while studies of home-based exercise programs have show a reductio i frequecy of ear-falls [39] ad PD-related fall risk [40]. It is evidet, therefore, that the assessed effectiveess of the multiple available itervetios may vary greatly depedig o the outcome measures used. Such measures, therefore, eed be tailored to the targeted eed of the specific itervetio. Accordig to the UK Natioal Cliical Guidelie for diagosis ad maagemet of PD, potetial targets for physical therapy may iclude ay of the f ollowig [11] : Gait re-educatio, improvemet of balace ad flexibility Ehacemet of aerobic capacity Improvemet of movemet iitiatio Improvemet of fuctioal idepedece, icludig mobility ad activities of daily l ivig Provisio of advice regardig safety i the home eviromet Naturally, appropriate outcome measures should be employed i assessig both the patiet s level of fuctio ad the effectiveess of physical therapy itervetios. Such measures have bee validated i PD ad iclude the Timed Up-ad-Go (TUG) [41,42] ad Five Times Sit-to-Stad Test (FTSST) [43] as overall mobility measures ad the Berg Balace Scale (BBS) [44] ad Tietti score [45] as measures of balace ad falls risk. Istrumeted versios of some of these tests [46] seem promisig, yet Review further studies are still ecessary to establish a gold stadard. Posturography has bee used i PD; however, its utility is beig debated [47]. Occupatioal therapy The purpose of occupatioal therapy i the treatmet of PD is the facilitatio of activities of daily livig. As mobility appears to be a pricipal requiremet for may such activities, the close collaboratio of the occupatioal therapist with the physical therapist withi the multidiscipliary team ca be viewed as havig a syergistic effect; a similar iteractio may be beeficial with the speech pathologist, sice commuicatio ad swallowig are fuctios that may be affected by PD ad are at the root of may of the everyday life activities. It is therefore ot surprisig that much of the occupatioal therapy i PD literature has examied this disciplie as part of a multidiscipliary approach [48] ad its effects are difficult to distiguish from the effects of the complemetary itervetios. Nevertheless, despite the relative lack of strog evidece, the use of occupatioal therapy is supported, based o a few small s tudies ad the body of cliical experiece [11,49]. Amog the guidig priciples of occupatioal therapy are early itervetio i order to maitai ad prevet the loss of abilities, ad patietcetered goal developmet ad therapy. The role of the occupatioal therapist withi the multidiscipliary team may vary, but the goal remais the facilitatio of activities of daily livig. Thus, occupatioal therapy itervetios may be as varied as traiig to improve dexterity, assessmet for, educatio about ad implemetatio of adaptive equipmet, cogitive assessmet ad traiig with regard to activities of daily livig. The occupatioal therapist may be further ivolved i evaluatio ad assistace with professioal ad leisure activities ad evirometal adaptatios to the work ad home eviromet, ad always aimig to facilitate the activities of everyday life. Give the variety of targets for occupatioal therapy itervetios, appropriate assessmet tools eed to be selected. As much of what the occupatioal therapist does overlaps to a degree with other disciplies, assessmet tools may be shared accordigly. Istrumets specifically assessig the activities of daily livig i patiets with PD are available, icludig the activities of daily livig sectio (part II) of the UPDRS 193

6 Review Parashos [34] ad the experieces of daily livig subscale of the Movemet Disorders Society (MDS) UPDRS [50]. Other scales of activities of daily livig, both PD-specific [51,52] ad geeric [53], may be implemeted; however, depedig o the goals of the particular itervetio, attetio will have to be paid to the appropriateess ad sesitivity to chage of the particular istrumets. Assessig istrumetal activities of daily livig [54 56] may provide a more objective measure of everyday life abilities; however, some of the objective istrumets may be hampered by cliimetric s hortcomigs, such as poor test retest reliability. Speech & laguage pathology The role of the speech therapist i PD is also cosiderably varied. PD affects ot oly articulatio, but also voice volume, iflectio ad prosody. O a cogitive level, the loss of metal flexibility, associated with frotal lobe dysfuctio i PD, ca affect ame ad word memory ad iterfere with the trai of thought ad the atural flow of coversatioal speech. This produces a cliical picture of laguage disturbace, further compoudig the commuicatio problems facig PD patiets. I certai cliical settigs, the role of the speech therapist ecompasses educatio ad couselig of patiets ad families o cogitive issues i PD ad eve ivolvemet i cogitive rehabilitatio therapeutic protocols. Last but ot least, it is withi the realm of speech therapy that assessmet ad treatmet of dysphagia lies. As importat as these areas of dysfuctio may be, ad despite umerous published studies with positive results, a critical review of the literature discloses o level 1 evidece to strogly support the utility of speech therapy i PD a fidig commo for most opharmacological t reatmets [57]. By far the therapeutic protocol that has attracted most attetio ad has gaied mometum i improvig speech i PD is the Lee Silverma Voice Treatmet, a method that has cosistetly produced improvemets i commuicatio ad health-related quality of life amog PD patiets [58,59]. Iterestigly, the Lee Silverma Voice Treatmet has also bee foud to improve swallowig fuctio i PD [60]. Other strategies of speech therapy have ot bee studied to the same extet ad some studies have show little, if ay, beefit from alterative speech therapy approaches [61,62]. 194 Cli. Pract. (2012) 9(2) Speech therapy assessmet tools may be subjective (i.e., stadardized questioaires pertaiig to commuicatio ad swallowig fuctios) [63 65] or objective (e.g., computerized voice ad speech aalysis ad video swallow study). Both types of istrumet are useful, as a lack of subjective improvemet may suggest that the treatmet was usuccessful i improvig the patiet s quality of life despite i mprovemets see i objective scales [65]. Other itervetios Besides the traditioal therapeutic approaches of physical, occupatioal ad speech therapy, there is a moutig corpus of medical literature o the utility of additioal complemetary itervetios i the cotext of the multidiscipliary treatmet of PD. Such itervetios iclude, but are ot limited to: Behavioral therapy [66] Cogitive rehabilitatio [67,68] Music therapy [69] Structured exercise ad dace [70 72] Social services Spiritual services Patiet ad care parter educatio Palliative ad ed-of-life care Although there is some evidece supportig such itervetios, the existig studies are geerally uderpowered. More, better-powered ad -desiged studies are goig to be ecessary for these promisig complemetary therapies to become part of the maistream treatmet of PD. Iterdiscipliary implemetatio A basic premise of the multidiscipliary model is the iterdiscipliary implemetatio. The ratioale is that commuicatio betwee the various disciplies will have a syergistic impact o the outcome of the itervetio. Oe may therefore argue, with reaso, that cosideratios that facilitate iteractio betwee disciplies, such as physical proximity of the various disciplies, accessibility, ease of commuicatio ad schedulig flexibility, will further icrease the likelihood of a positive outcome. Team reviews of cases are the stadard of care for ipatiet rehabilitatio programs ad there is o reaso to ot adopt a similar approach i the outpatiet

7 Multidiscipliary treatmet of Parkiso s disease: curret state & future directios settig. Iclusio of patiets ad care parter, or family members i the multidiscipliary meetigs will further esure future implemetatio of recommedatios beyod discharge from the program. It has bee the experiece of this author that providig patiets ad care parters with writte directios, additioal educatioal material ad recordigs of care cofereces is both useful ad appreciated at the time of d ischarge ad beyod. Settig Although the majority of the literature o the multidiscipliary treatmet of PD refers to itervetios i the ambulatory settig, there has bee excellet work doe ad published i hospitalized PD patiets [10,73] ; also i the recet settig of postoperative care followig deep brai stimulatio surgery for PD [74]. Costraits from the curret reimbursemet structure for hospitalizatio i the USA may have hidered more i-depth studies of the effectiveess of ipatiet multidiscipliary rehabilitatio i PD; however, there is certaily evidece to suggest that this approach may i fact prove cost effective. More large, well-desiged studies will be ecessary to prove the poit ad alter curret practice. Follow-up Review hadle the balace challeges of advaced PD. It has bee hypothesized, with good reaso, that there may be physiological alteratios caused by exercise that may have log-term effects i the pathophysiological processes uderlyig the symptoms of PD [75]. But eve i terms of short-term follow-up very little is kow from the existig literature. How log ca oe expect the beefits of a certai itervetio to last? Is there a eed for follow-up visits? Is there a poit for periodic refresher or booster sessios? It would be therefore desirable that future studies of multidiscipliary itervetios i PD iclude some type of both short- ad log-term follow up assessmets. Coclusio & future perspective I summary, the multidiscipliary treatmet of PD remais a poorly studied but rather promisig field, i terms of eed for further research, but also i terms of improvig the lives of PD patiets ad their families. I a era of evidecebased medicie, it is importat that ew studies are udertake, preferably takig ito accout the cosideratios discussed i this article ad usig rigorous scietific stadards that ca stad up to the requiremets of evidece-based reviews. Much of the existig literature o the subject lacks follow-up data. Log-term beefits of the therapeutic disciplies metioed above are etirely ukow. Thus, it is reasoable to ask, for example, whether early participatio i a structured exercise program will improve a patiet s progosis i terms of fall-related adverse disease outcomes. Oe might argue that a traied idividual will be able to better 2 Taer CM, Thele JA, Offord KP, Rademacher D, Goetz CG, Kurlad LT. Parkiso s disease (PD) icidece i Olmsted Couty, MN: [abstract]. Hely MA, Morris JGL, Reid WGJ, Trafficate R. Sydey multiceter study of Parkiso s disease: o-l dopa resposive problems domiate at 15 years. Mov. Disord. 20, (2005). Braak H, Ghebremedhi E, Rub U, Bratzke H, DelTredici K. Stages i the developmet of Parkiso s disease-related pathology. Cell Tissue Res. 318(1), (2004). 4 Uitti RJ, Ahlskog JE, Maragaore DM et al. Levodopa therapy ad survival i idiopathic Parkiso s disease: Olmsted Couty project. Neurology 43, (1993). 7 Lim SY, Lag AE. The omotor symptoms of Parkiso s disease a overview. Mov. Disord. 25(Suppl. 1), S123 S230 (2010). 5 Parashos SA, Maragaore DM, O Brie PC, Rocca WA. Medical services utilizatio ad progosis i Parkiso s disease: a populatio-based study. Mayo Cli. Proc. 77, (2002). 8 Wade DT, Gage H, Owe C et al. Multidiscipliary rehabilitatio for people with Parkiso s disease: a radomised cotrolled study. J. Neurol. Neurosurg. Psychiatry 74, (2003). Morgate L, Rocca WA, Di Rosa AE et al.; Sicilia Neuro-Epidemiologic Study (SNES) Group. Prevalece of Parkiso s disease ad other types of Parkisoism: a door-to-door survey i three Sicilia muicipalities. Neurology 42, (1992) The author has o relevat affiliatios or fiacial ivolvemet with ay orgaizatio or etity with a fiacial iterest i or fiacial coflict with the subject matter or materials discussed i the mauscript. This icludes employmet, cosultacies, hooraria, stock owership or optios, expert t estimoy, grats or patets received or pedig, or royalties. No writig assistace was utilized i the productio of this mauscript. Neurology 42(Suppl. 3), Abstract 198S (1992). Refereces Papers of special ote have bee highlighted as: of iterest of cosiderable iterest Fiacial & competig iterests disclosure 195

8 Review Parashos This study is a radomized cotrolled crossover trial comparig Parkiso s disease (PD) patiets ad carers who had received rehabilitatio 4 moths before assessmet with those who had ot. Those receivig rehabilitatio had a tred towards better stad walk sit score, but worse geeral ad metal health. The authors cocluded that patiets with PD declie sigificatly over 6 moths, but a short spell of multidiscipliary rehabilitatio may improve mobility. Care W, Cifu D, Marciko P et al. Efficacy of a multidiscipliary treatmet program o oe-year outcomes of idividuals with Parkiso s disease. NeuroRehabilitatio 20(3), (2005). This is a review of the impact of the multidiscipliary cliical maagemet withi the Veteras Affairs Parkiso s Disease Research, Educatio, ad Cliical Ceter program o PD progressio. The mai outcome was improvemet or worseig i the motor subscale score (Part III) of the UPDRS. Overall, 37 (75.5%) of the 49 patiets demostrated stable or improved UPDRS motor scores at 1 3-year follow-up. Multidiscipliary itervetios icluded eurology, physiatry, ursig, psychology, medicatio chages, rehabilitatio therapies (physical, occupatioal, speech laguage, fuctioal diagostic testig, support group, home exercise istructio, ad disease ad welless educatio). Ellis T, Katz DI, White DK, DePiero TJ, Hohler AD, Sait-Hilaire M. Effectiveess of a ipatiet multidiscipliary rehabilitatio program for people with Parkiso disease. Phys. Ther. 88(7), (2008). Sixty eight PD patiets participated i a ipatiet rehabilitatio program cosistig of a combiatio of physical therapy, occupatioal therapy ad speech therapy, i additio to pharmacological adjustmets. At discharge, there were improvemets i the Fuctioal Idepedece Measure (total, motor ad cogitive scores), Timed Up & Go Test, 2-Miute Walk Test ad Figer Tappig Test. Natioal Collaboratig Cetre for Chroic Coditios. Parkiso s Disease: Natioal Cliical Guidelie for Diagosis ad Maagemet i Primary ad Secodary Care. Lodo: Royal College of Physicias, Lodo, UK (2006). A extesive review of the existig evidece followed by guidelies ad recommedatios Gage H, Kaye J, Owe C, Tred P, Wade D. Evaluatig rehabilitatio usig cost cosequeces aalysis: a example i Parkiso s disease. Cli. Rehabil. 20(3), (2006). Johsto M, Chu E. Does attedace at a multidiscipliary outpatiet rehabilitatio program for people with Parkiso s disease produce quatitative short term or log term improvemets? A systematic review. NeuroRehabilitatio 26(4), (2010). WHO. Towards a Commo Laguage for Fuctioig, Disability ad Health ICF. WHO, Geeva, Switzerlad (2002). 15 Tred P, Kaye J, Gage H, Owe C, Wade D. Short-term effectiveess of itesive multidiscipliary rehabilitatio for people with Parkiso s disease ad their carers. Cli. 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