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  • Physical Therapy 'Ineffective' for PD? Headlines Overstate Study's Conclusions

    A recent study from England involving physical therapy, occupational therapy, and individuals with Parkinson Disease (PD) has generated plenty of dramatic headlines about physical therapy's supposed "ineffectiveness." But as is often the case with dramatic headlines, there's more to the story.

    The study in question, published in JAMA Neurology (abstract only available for free), aimed to evaluate the clinical effectiveness of individualized physical and occupational therapy for individuals with PD by comparing outcomes at baseline and 3 months among 381 participants who received treatment with an equally sized control group that didn't.

    Researchers found little to no difference in outcomes primarily based on the Nottingham Extended Activities of Daily Living (NEADL) scale, and secondarily based on the Parkinson Disease Questionnaire-39 and the EruoQol-5D, writing that "physiotherapy and occupational therapy were not associated with immediate or medium-term clinical improvements in [activities of daily living] or quality of life in mild to moderate PD."

    Headlines ensued. "Parkinson's patients may not benefit from physical therapy," wrote United Press International. "Physical, Occupational Therapy Ineffective in Parkinson," was how Medscape framed the study. "Millions of pounds wasted providing physiotherapy for Parkinson's say researchers," was the headline at the UK newspaper The Telegraph. Several other news outlets took a similar approach.

    While dramatic, the headlines may be off the mark. According to researcher and physical therapy professor Theresa Ellis, PT, PhD, NCS, the study may have more to say about a particular intervention model used in England than it does about the effectiveness of physical therapy on individuals with PD.

    Ellis identifies several issues that may not make the study suitable for generalization. Among them: a low dosage of physical therapy (median number of physical therapy sessions received was 4, meaning that half of all treatment participants received fewer than 4 sessions); widely variable expertise among the physical therapists (PTs) delivering services; the use of 38 different sites for interventions; a wide range of severity among participants; the use of an outcome measure (NEADL) that has not been validated for use in PD; and little attention paid to participants' follow-through, particularly in relation to any homework assigned. "Essentially, most participants had 1 to 2 therapy sessions followed by nothing over 15 months," Ellis said.

    "The very low dose of therapy—below what is typically provided in the US—and the absence of an ongoing home exercise program contribute substantially to the lack of improvement observed," Ellis said. "Other studies in Parkinson, in which larger doses of physical therapy were provided, reveal improvements in walking, functional mobility, and balance."

    Authors of the study admit that the number of sessions was relatively low, but argue that the dosage reflects common practice in England, and that other studies that incorporated more sessions yielded results similar to theirs. Still, they were careful to limit their conclusions only to the effectiveness of low-dose physical and occupational therapy that uses "an individual goal-setting approach" on patients with mild-to-moderate PD, and then only to short and medium-term benefits in activities of daily living or quality of life.

    According to Ellis, even those more narrow conclusions may be questioned. For Ellis, 1 potential problem is the fact that about a third of the patients in the study were in the more severe stages of PD. Another issue: among the mild-to-moderate group, "a substantial number scored at the upper limits of their measure [at baseline], making it impossible to show any progress in these participants," Ellis said.

    While authors of the study hold to their conclusions about the effectiveness of low-dose physical and occupational therapy for individuals with mild-to-moderate PD, they acknowledge that more research is needed—particularly around "the development and testing of more structured … therapy programs in patients with all stages of PD"—the kind of nuance that apparently isn't the stuff of headlines.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Teri Ellis and MaragaryenSxhenkman co-authored a clinical summary about management of person with PD. The original version can be found on PTNow. The update will be posted sometime this year.

      Posted by Judith Deutsch on 1/27/2016 6:02 PM

    • Appreciate Terry revealing the limitations of this study. For these reasons, people should not get stuck on a headline and take a deeper look into studies to make judgments for themselves. It is unfortunate that those with PD or their caregivers who read this may choose to forego physical therapy simply because of this study that has significant limitations. Ryan Duncan, PT, DPT

      Posted by Ryan Duncan on 1/27/2016 6:31 PM

    • This situation emphasizes the ever present need for well designed physical therapy studies with appropriate numbers of subjects, controlling bias and confounding influences, validated measures, a thorough scientific discussion and conclusions based on solid statistics. While attending 2 CME courses this month, I was not impressed with the presenters’ enthusiastic extolling the therapeutic benefits of kinesiology taping based on their individual case studies with “n” of 1. They did not present the scientific foundation for their claims. We need to be the guardians of our profession and maintain the highest standards of research in order to provide high quality evidence based physical therapy.

      Posted by Steven Hunte on 1/27/2016 7:48 PM

    • Although I have not performed a formal research study on results of physical therapy treatment in Parkinson's Disease, I can state that in my 25 years of practice my patients have received benefit from learning movement strategies, especially involving transfer techniques and resting postural modifications, which have diminished their number and severity of subsequent falls and improved the quality of their movement as reported by the patients and their caregivers. Breathing exercises, balance training, and strengthening programs have been particularly helpful in initiation of gait and transfers. Thank you for your interest in my clinical observations. Mary C. Hodge, P.T.

      Posted by Mary C. Hodge, P.T. on 1/27/2016 8:43 PM

    • This shows the difference between research and a newspaper article.

      Posted by Herb karpatkin on 1/27/2016 10:20 PM

    • The analysis of the research design and its flaws by Dr. Terri Ellis is insightful and spot on. The use of low dose therapy sessions and heterogeneity of the subjects calls into question the study's validity and generalizability. The generation of dramatic headlines and the view that physical therapy is ineffective and wasteful is indeed unfortunate.

      Posted by Susan B OSullivan on 1/28/2016 10:07 AM

    • We have 14 classes in Wisconsin that all meet 2 times a week and are supervised by PT's with background in motor control. These classes of 25-30 min of treadmill (3 directions) & strengthening for at least 30 minutes. We do incorporate clients who are very involved. Check the website for published articles, locations, assessment and treatment. Terry Steffen, PhD, PT

      Posted by Teresa Steffen on 1/28/2016 11:29 AM

    • Great job, Terry!

      Posted by Ginger Walls on 1/28/2016 2:01 PM

    • This study falls short in my opinion. It is known that high amplitude and high intensity exercise is of great benefit to patient's with Parkinson's and other Parkinsonian features, but must be consistent and of reasonable duration. The findings of this study support what we as clinicians already see clinically when a patient only receives a couple treatments with low intensity. Unintentionally, the conclusions of this study are attempting to derail how far we have come in treating patients with Parkinson's. The people who ran this study should have asked themselves what exact question they are wanting to answer and realized that no one who is efficacious with treating Parkinson's would chose to prescribe mildly intense plan of cares with such small durations.

      Posted by Konrad on 1/28/2016 2:55 PM

    • Steven Hunte, I am in complete agreement with you. Well said.

      Posted by Caryn McAllister -> =NWc>M on 1/29/2016 7:57 AM

    • This research and all the hub-bub around it smacks of what Big Pharma and our insurance companies like to do with alternative medicine information in the States. Is the UK stooping so low. Of course this research is flawed but why? Why would anyone with any ethical substance think 2-4 treatments would miraculously change the course of PD. I think this is a way of discrediting services so the government doesn't have to pay. Sound familiar.

      Posted by Carla Becker on 1/29/2016 9:50 AM

    • Lumping OT with PT is always suspect. We are distinct professions. When discussing "physical and occupational therapy" it should be physical therapy and occupational therapy. There are some who think we are the same profession.

      Posted by Fran Delaney, PT, DPT, MS on 1/31/2016 2:36 PM

    • I'm an author and the point many people are missing is that the NHS service and therapists determined the intervention, at over 40 uk sites. We did not. So the study has found what is delivered in the NHS is ineffective. Should the resource be moved to late stage PD, should we test higher intensity, lots of questions. But this was a well designed and conducted, adequately powered, large study and we should build on the science.

      Posted by Cath Sackleg on 2/18/2016 1:43 AM

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