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Bloem B (2004)
KNGF clinical practice guideline for physical therapy in patients with Parkinson’s disease.Dutch J Physiotherapy, 144
T. Ellis, Jennifer Boudreau, T. DeAngelis, Lisa Brown, James Cavanaugh, G. Earhart, M. Ford, K. Foreman, Leland Dibble (2013)
Barriers to Exercise in People With Parkinson DiseasePhysical Therapy, 93
I. Shrier, R. Steele, E. Verhagen, Rob Herbert, C. Riddell, J. Kaufman (2014)
Beyond intention to treat: What is the right question?Clinical Trials, 11
C. Clarke, Smitaa Patel, N. Ives, C. Rick, F. Dowling, R. Woolley, K. Wheatley, M. Walker, C. Sackley (2016)
Physiotherapy and Occupational Therapy vs No Therapy in Mild to Moderate Parkinson Disease: A Randomized Clinical Trial.JAMA neurology, 73 3
To the Editor I read with interest the article by Clarke et al.1 They provide an interesting randomized clinical trial showing physiotherapy (PT) and occupational therapy (OT) are not associated with immediate or medium-term clinically significant improvements in activities of daily living or quality of life in mild to moderate Parkinson disease (PD). Low doses of PT and OT were delivered in the community or outpatient setting by therapists working within the UK National Health Service per local practice. During 8 weeks of treatment, patients received a median of 4 therapy sessions (mean of 58 minutes each); the mean total dose of both therapies was 263 minutes. Considering 8 weeks have 56 days, the mean of delivered therapy was only 4.69 minutes of both therapies per day. It may be classified, optimistically, as a low dose or, realistically, as an impressive PT/OT treatment nonadherence. Despite intention-to-treat analysis advantages, we need to consider the underestimation of the treatment effect when high levels of nonadherence to the proposed intervention is found.2 Usual National Health Service practice and European guidelines presume beneficial effects considering patients will be adherent to the therapy.3 At this scenario, concluding PT and OT cannot help mild to moderate PD without assessing causes of nonadherence (some of them might be easy to solve) may be misleading or, at least, premature. With intention-to-treat analysis, it is thus imperative to design and conduct studies for maximum patient retention and adherence.2 For example, depression (up to 50% of patients have depressive symptoms), anxiety, and abulia or apathy are common mood disorders that occur in patients with PD and may be associated with poor PT/OT engagement.4,5 Thus, an interdisciplinary approach, ie, including an effective mental health support, might be critical to increase adherence5 and, probably, PT/OT treatment efficacy in patient-centered neurorehabilitation programs. Further studies evaluating reasons for nonadhesion are needed before establishing a definitive clinical evidence for discontinuing current PT/OT guidelines in mild to moderate PD. Back to top Article Information Corresponding Author: Régis Gemerasca Mestriner, PT, PhD, Pontifical Catholic University of Rio Grande do Sul, Nursing, Nutrition and Physiotherapy College, Av Ipiranga, 6681, Porto Alegre, Rio Grande do Sul 90619-900, Brazil (regis.mestriner@pucrs.br). Published Online: May 31, 2016. doi:10.1001/jamaneurol.2016.1280. Conflict of Interest Disclosures: None reported. References 1. Clarke CE, Patel S, Ives N, et al; PD REHAB Collaborative Group. Physiotherapy and occupational therapy vs no therapy in mild to moderate Parkinson disease: a randomized clinical trial. JAMA Neurol. 2016;73(3):291-299.PubMedGoogle ScholarCrossref 2. Shrier I, Steele RJ, Verhagen E, Herbert R, Riddell CA, Kaufman JS. Beyond intention to treat: what is the right question? Clin Trials. 2014;11(1):28-37.PubMedGoogle ScholarCrossref 3. Keus S, Hendriks H, Bloem B, et al. KNGF clinical practice guideline for physical therapy in patients with Parkinson’s disease. Dutch J Physiotherapy. 2004;144(3).Google Scholar 4. Chou KL. Clinical manifestations of Parkinson disease. UpToDate. http://www.uptodate.com/contents/clinical-manifestations-of-parkinson-disease. Accessed February 15, 2016. 5. Ellis T, Boudreau JK, DeAngelis TR, et al. Barriers to exercise in people with Parkinson disease. Phys Ther. 2013;93(5):628-636.PubMedGoogle ScholarCrossref
JAMA Neurology – American Medical Association
Published: Jul 1, 2016
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