Exploring physiotherapy for Parkinson s disease: A Delphi survey Presented by: Charmaine Meek, Research Physiotherapist Primary Care Clinical Sciences, University of Birmingham On behalf of the PD REHAB study group
Background: The need for a clear definition of physiotherapy Physiotherapy is viewed as essential within the management of people with Parkinson s disease (PD). Its inclusion in the care of PD patients is supported by national guidelines, and there is a growing body of evidence suggesting its efficacy. A recent survey by Parkinson s UK (formally the Parkinson s Disease Society; PDS, 2008), noted an increase in the utilisation of physiotherapy by patients in the UK, with 54% of respondents accessing physiotherapy. However, our understanding of what physiotherapy should entail for this population is limited.
Background: The need for a clear definition of physiotherapy Current evidence exploring the definition, structure and content of physiotherapy practice for PD: Dutch surveys (Keus et al, 2004; Nijkrake et al, 2009) PD: Physiotherapy Evaluation Project (Plant et al, 2000) Further evidence is now required following the publication of a number of large efficacy trials, as UK physiotherapy practice may have changed. A survey of physiotherapy practice within the UK would provide a framework to: 1. Inform the physiotherapy intervention delivered within the PD REHAB trial. 2. Promote equality in clinical practice
Aims of the Delphi survey To conduct a survey to explore best practice physiotherapy for people with PD, uncovering what UK physiotherapists identify as: The reasons for providing physiotherapy The core areas of physiotherapy Perceived effective treatment techniques and modalities The outcomes that should be measured when managing PD To obtain information on the current structure and delivery of UK physiotherapy services
Methods of the Delphi survey Design A two round modified Delphi survey with additional closedquestion questionnaire Participants Clinical physiotherapists or research physiotherapists with an interest/ expertise in the management of people with PD Setting Conducted from the University of Birmingham and disseminated to members of the Delphi panel via email
Design of the Delphi survey Generation of Delphi statements First round of Delphi Literature search conducted to uncover relevant evidence Literature analysed and graded for strength Statements created Statements rated for agreement or disagreement on a Likert scale Option given for additional feedback Second round of Delphi Questionnaire repeated, incorporating the group s first round responses. Statements re-rated in light of the first round responses. Analysis of results for consensus Consensus for a statement is reached if 80% or more respondents present in agreement on the Likert scale. Report findings
Results: Delphi and questionnaire response Out of a database of 107 therapists: 76 (71%) responded to the first round of the Delphi 61 (80%) responded to the second round of the Delphi 70 participants completed the additional closed question questionnaire
Findings from the optional questionnaire
Respondent characteristics Mean number of years qualified: 17.6 years (range 3-40) Number of PD patients treated in the past year: median 25 (range 3-250) 54% working full time 85% identified themselves as having a specific interest in PD 60% had received post-graduate training applicable to PD management 89% of those who hadn t received post-graduate training would like to
Structure and delivery of services Referral Majority of referrals made to physiotherapy services by the PD nurse specialist 45% of services allowed initial patient/ carer self referral 78% of services allowed patients to re-access physiotherapy through self referral Majority of referrals reported to occur in the maintenance and complex phases of the disease Setting Therapy predominantly delivered in the patient s home or outpatient setting
Structure and delivery of services Structure 75% delivered physiotherapy within a multidisciplinary team format Only 25% delivered care co-ordinated by a key worker (most often a PD nurse specialist) 52% of therapists delivered physiotherapy combining individual and group sessions 43% of therapists delivered physiotherapy through individual sessions only Course of physiotherapy Median of 6 sessions per course of physiotherapy (range 1-20) Median of 60 minutes for the initial assessment (range 30-90) Median of 45 minutes for follow up sessions (range 20-75) Course of therapy delivered over a median of 8 weeks (range 1-39)
Findings of the Delphi survey
Delphi survey: Reasons for physiotherapy Consensus for all statements Minimise secondary complications Quality of movement Functional independence Support self management Prevent fear of falling Improve/ maintain/ minimise degeneration of Support patient involvement in work and leisure Promote safety in the home environment Balance General fitness Management of pain Provide information and education
Delphi survey: Core areas of physiotherapy Consensus No Consensus Body functions and structures Activities Participation Gait Indoor mobility Leisure Freezing of gait Balance Transfers Posture Physical conditioning Upper limb function Respiratory functioning Pain management Outdoor mobility Work Falls Self-care Domestic ADL Body functions and structure Psychological issues Activities Communication
Delphi survey: Treatment within physiotherapy Patient specific Task specific Carer involvement (based on individual needs of the patient) Encourage development of problem solving skills Treatment Patient determined goals Physiotherapy available from diagnosis Collaborative working within the MDT Physiotherapy delivered in both individual and group sessions Give patients time to process information
Perceived effective treatment techniques: Gait Consensus External cueing techniques (visual/ auditory/ sensory/ verbal prompts) Cognitive movement strategies No Consensus Dual task avoidance Dual task training Lower limb strengthening exercises Joint mobility exercises Functional walking practice (obstacles, turning etc) Walking practice utilising patient s environment Education and practice using walking aids Mental rehearsal Compensatory strategies
Perceived effective treatment techniques: Balance Consensus No Consensus Multifaceted, progressive exercise programmes Education on pelvic control for balance Rehabilitation based in a variety of settings (indoor and outdoor) Teaching and practising how to get on and off the floor Axial control and coordination exercises Secondary effects of gait rehabilitation (cueing and cognitive strategies)
Perceived effective treatment techniques: Transfers Consensus for all statements Cognitive movement strategies External cueing techniques Education and practice with equipment Home environment assessment Rehabilitation optimised through task specificity Education and training of carers
Perceived effective treatment techniques: Physical conditioning Consensus Resistance exercises Joint mobility/ flexibility exercises No Consensus Positioning and passive stretching Cardiorespiratory training Posture rehabilitation to support cardiorespiratory capacity Manual techniques (e.g. mobilisations) for joint mobility/ flexibility Recreational activity/ selfmanagement Referral to leisure facilities Functional, task specific training Education
Perceived effective treatment techniques: Posture Consensus No Consensus Axial control and coordination exercises Hands on facilitation of body alignment Strengthening of the core muscles Manual techniques (e.g. mobilisations) Verbal and visual feedback Education Use of equipment and aids Passive and positional stretching
Perceived effective treatment techniques: Upper limb Limited evidence and lack of consensus Consensus No Consensus Resistance and range of movement exercises Upper limb coordination exercises External cueing techniques Internal cueing techniques Functional training (e.g. dexterity)
Provision of additional treatment and complementary therapies Consensus: Breathing exercises for management of respiratory complications No consensus: Manual chest physiotherapy for respiratory complications, management of pain (acupuncture, TENS, massage, prolonged stretching) No consensus: Inclusion of complementary therapies (Alexander technique, Pilates, Tai Chi, Yoga)
Outcome measurement Specific aims and effects of treatment delivered Effectiveness of treatment delivered at the level of activity performance Effect on overall physical functioning Outcome measures should assess the Effect on health-related quality-of-life and wellbeing Impact of treatment on the patient s carer but not the effects of treatment at the level of body structure and function, or participation (ICF model)
Outcome measurement Outcome measurement should be: Objective in nature, either with or without additional subjective measures Recorded pre and post treatment to monitor change Recorded over an extended period of time in order to monitor disease progression The findings of outcome measurement should be used to influence future practice
Top outcome measures used in practice Berg balance scale (43*) Lindop PD assessment (26*) 10 metre walk (25*) TUG (16*) TUAG (15*) Tinnetti (13*) Functional reach (11*) Elderly mobility scale (10*) UPDRS/ 6 min walk test/ 360 degree turn/ tragus to wall in standing (7*) 180 degree turn (6*) * : number of respondents listing outcome out of 65
Conclusions Current services Responding therapists were highly experienced in both years qualified and number of patients seen. Physiotherapy is predominantly delivered in the patient s home or an outpatient setting, often combining both group and individual sessions. The physiotherapist often acts as part of a MDT. The PD nurse specialist plays a central role in referral to physiotherapy services, although the possibility of patient/ carer self referral is becoming more prominent in practice. Despite support for physiotherapy in all stages of PD, the majority of referrals are still only made in the maintenance and complex phases The dose of therapy delivered is comparable to that proposed following the PD: physiotherapy evaluation project (Plant et al, 2000) and current occupational therapy practice as reported by Deane et al (2003).
Conclusions Delphi survey of perceived best practice There are high levels of consensus regarding the reasons for delivering physiotherapy, and the core areas focused upon in practice. These reasons and core areas are wide ranging, covering all levels of the ICF model Treatment is perceived to be best when task and patient specific. There are high levels of consensus for the perceived effective treatment techniques for gait and balance, perhaps due to the increased levels of high quality evidence in these areas. Despite being recognised as core areas, there is less consensus around the treatment of posture and the upper limb. Outcome measurement predominantly focuses on the activity level of the ICF model, as illustrated by the outcome measures used most often in practice. The reported use of outcome measures in practice was much higher than previously reported in the literature.
References DEANE, K. H. O., ELLIS-HILL, C., DEKKER, K., DAVIES, P. & CLARKE, C. E. (2003a) A survey of current occupational therapy practice for Parkinson's disease in the United Kingdom. British Journal of Occupational Therapy, 66, 193-200. KEUS, S. H. J., BLOEM, B. R., VERBAAN, D., DE JONGE, P. A., HOFMAN, M., VAN HILTEN, B. J. & MUNNEKE, M. (2004) Physiotherapy in Parkinson's disease: utilisation and patient satisfaction. Journal of Neurology, 251, 680-7. NIJKRAKE, M. J., KEUS, S. H. J., OOSTENDORP, R. A. B., OVEREEM, S., MULLENERS, W., BLOEM, B. R. & MUNNEKE, M. (2009) Allied health care in Parkinson's disease: referral, consultation, and professional expertise. Movement Disorders, 24, 282-6. PDS (2008) Life with Parkinson s today room for improvement. Results of the UK s largest ever survey of people with Parkinson s and carers, London, PDS. PLANT, R., JONES, D., WALTON, G., ASHBURN, A., LOVGREEN, B., HANDFORD, F., KINNEAR, E. (2000) Guidlines for Physiotherapy Practice in Parkinson's Disease. Parkinson's Disease: Physiotherapy Evaluation Project UK Team.
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