Abstract
The evidence for physiotherapy is growing, showing a positive impact on functional activities involving gait, transfers and balance. Specific recommendations for physiotherapists, physicians and people with Parkinson’s disease were published in the European Physiotherapy Guideline for Parkinson’s disease. Here, we summarize the referral criteria, highlight the importance of accurate referral to specialized physiotherapists, and emphasize the potential benefits of expert care. As such, this paper offers very practical guidance for clinicians working with Parkinson’s disease patients and who consider physiotherapy treatments for their patients.
Keywords
The management of Parkinson’s disease (PD) presents many challenges for both patients and healthcare professionals. Despite optimal pharmacological treatment, many persons with PD increasingly experience motor and non-motor symptoms [1]. The evidence for non-pharmacological interventions such as physiotherapy is growing, showing a positive impact on functional activities involving gait, transfers and balance [2–4].
In 2014, the European Physiotherapy Guideline for Parkinson’s Disease was developed in a unique collaboration between 19 professional physiotherapy associations and persons with PD [2]. The guideline provides practical and evidence-based information for physiotherapists, as well as information about the systematic development process and scientific justification. Moreover, two specific sections were written for patients and physicians. The medical section was mainly envisioned to help reduce potential factors for non-referral or misconceptions regarding physiotherapy among physicians (e.g., Physiotherapy only needed at later stages; there is no data supporting the efficacy of physiotherapy; patients do not adhere; high dropout rate, etc.). The amount and strength of the evidence that supports the guideline recommendations [2], however allow us to refute these misconceptions and firmly recommend physiotherapy for all people with PD.
Here, we summarize the specific recommendations for physicians. We summarize the referral criteria, highlight the importance of accurate referral to specialized physiotherapists, and emphasize the potential benefits of expert care.
REFERRAL CRITERIA
Referral criteria for persons with Parkinson’s disease to physiotherapy
These recommendations are in line with those of the American Academy of Neurology, who recommend physicians to discuss the potential of physiotherapy with persons with PD at least once a year [5]. Shortly after the diagnosis, a referral can be considered, mainly for advice on exercise and self-management. For later disease stages, appropriate reasons to consider a referral to physiotherapy include patients who express difficulties with transfers, mobility, physical capacity, pain, gait (including freezing), balance or falls [6–9]. Various types of recommended interventions are available, such as (1) treadmill training, (2) teaching of compensatory strategies (including cueing), (3) training of dual task performance, and (4) training of active, large amplitude functional-task exercising addressing gait, balance, transfers and physical capacity (e.g., LSVT BIG). There are also community exercises, e.g., dance, Nordic walking, boxing or Tai Chi that are recommended for early stages (i.e., upon diagnosis) and upon completion of a physiotherapy treatment period as means of maintenance of a status quo or towards reduced speed of deterioration.
Additionally, several standardized measurement tools are used to gain systematic insight into current problems and to decide whether physiotherapy intervention is indicated. Newly recommended tests in the guidelines include the Mini-BESTest, the Dynamic Gait Index and the Five Times Sit To Stand. The Goal Attainment Scaling is recommended to describe and evaluate SMART (Specific, Measurable, Attainable, Relevant and Time-based) goals, set by the physiotherapist and patient collaboratively.
Importantly, some indications for non-referral may include: (1) Patients with significant active psychiatric problems (for example: severe hallucinations, confusion, persistent depressed mood, or psychosis etc.) that may be aggravated when doing exercises; (2) Presence of red flags that would motivate interruptions of physiotherapy (i.e., severe cardiovascular impairments, recent pulmonary embolism, etc.); and (3) Patients that do not have ability to correctly participate in physiotherapy according to the referrers judgment.
SPECIALISED OR GENERICALLY TRAINED PHYSIOTHERAPISTS?
Are there any merits to referring patients to specialized care, or is referral to usual care (generically trained physiotherapist) enough? The guideline recommends referral to a physiotherapist with expertise in PD. This recommendation is based on steadily increasing evidence that physiotherapy interventions are delivered best by therapists who have received dedicated training in the management of patients with PD [2, 10–12].
While there is no golden standard for ‘Parkinson’s-expertise’ and specific training still varies among countries, this phenomenon is mainly associated with the number of people with PD treated annually (annual case load of >7) [10]. As such, in the guidelines, Physiotherapists are advised to have a higher than average patient volume, but also to closely collaborate with other health care providers with PD expertise and engage in continuous, up-to-date PD-related education from (inter)nationally recognized experts.
There are several reasons why experts are better than generically trained therapists. First, Parkinson experts are trained according to evidenced-based guidelines, such as the new European Physiotherapy Guideline. These experts are more likely to adopt best practice and deliver better interventions, particularly regarding issues of safety and prevention of falls [2, 13]. Second, Parkinson experts are more likely to attract and treat many patients, and thereby progressively accumulate more experience. Finally, expert physiotherapy as delivered for example through the ParkinsonNet model of care that was introduced in the Netherlands in 2004, has been associated with better quality of care, fewer PD-related complications, and lower healthcare costs [12, 14]. The Tel Aviv Sourasky Medical Center model of interdisciplinary care is another example and reflects the benefits of specialized care in different settings such as inpatient facility, community rehabilitation facility, and multiprofessional modalities in the community [15].
Nearly all patients will follow their physician’s advice when being referred for physiotherapy. Moreover, when patients are already being treated by generically trained therapists, they are willing to switch to an expert therapist who understands the complexity of their disease and who is up to date with current physiotherapy interventions for PD [16, 17]. Unfortunately, access to physiotherapy services varies widely, even in western countries. For example, a survey among 1752 persons with PD from 32 European countries revealed great differences in availability and reimbursement of physiotherapy services across Europe [18]. Overall, around 68% of respondents indicated having access to physiotherapy and it was perceived as ‘very helpful’ by 54% of patients, making physiotherapy the best accessible and subjectively helpful allied health service [18]. When there is no physiotherapist available with specialised training in PD management, it seems reasonable to refer patients consistently to a limited number of motivated therapists, aiming to increase their caseload. Treating a high volume of patients seems associated with better care delivery and better outcomes for patients [10].
CONCLUDING REMARKS
The European Physiotherapy Guideline for Parkinson?s Disease was developed and published to support physiotherapists in their management of persons with PD, based on a thorough review of the latest scientific evidence. The guideline was originally published in English, and now there are already three translated versions (Portuguese, German, and Finnish), all of which are freely available for downloading at http://www.parkinsonnet.info/euguideline. Importantly, we here draw attention to the fact that the guideline also offers a set of specific recommendations for physicians, in particular with respect to criteria for referral. We hope that this will lead to a more timely and accurate referral of patients, allowing them to benefit from the growing menu of evidence-based interventions in this field. The same criteria can also help to avoid inadvertent referral of patients without a real need for physiotherapy interventions, thereby reducing unnecessary treatments and reserving the sparse resources for patients who truly require interventions most. Finally, the guideline also identifies gaps in knowledge and areas of unmet need, thus creating a basis for future clinical trials to obtain further evidence on optimal physiotherapy and other forms of non-pharmacological management.