Movement Disorder Section response to recent PD-REHAB trial findings

The results of the PD-REHAB trial by Clarke et al were published recently in JAMA Neurology1.  This UK based trial sought to determine the effect of physiotherapy (PT) and occupational therapy (OT) intervention versus no therapy on activities of daily living and quality of life.  The trial enrolled 762 patients in whom there was clinical equipoise as to the benefit of PT and OT over the next 15 months. Patients with an evident need were specifically excluded.  The primary outcome was the Nottingham Extended Activities of Daily Living (NEADL) Scale total score and secondary outcomes included quality of life and carer well-being measures. The participants in the study had a mean age of 70 years and relatively early stage Parkinson's disease (median disease duration 3.1 years). The participants in the PT/OT intervention group received on average, four sessions of therapy, each lasting just under an hour. Few physiotherapists (n=3) provided PD specific intervention.  OT input predominantly consisted of equipment provision, advice and onward referral to other services. The authors report that PT and OT intervention did not lead to a significant difference in the NEADL score, the two quality of life measures (Parkinson's Disease Questionnaire-39 score (PDQ-39) or EuroQoL-5d (EQ-5D)), nor carer well-being.

We commend the study authors for undertaking a large, pragmatic trial addressing such an important issue. However, we advocate caution in interpreting these findings as showing 'no benefit' of occupational and physiotherapy input in early Parkinson's disease. The patients enrolled had relatively early stage disease and importantly excluded those whom clinicians thought would benefit from PT/ OT intervention i.e. those in whom benefit would most likely be seen. The intervention was not Parkinson's disease specific, was low in volume and delivered over a relatively short time period. Crucially, the authors of the study highlight that exercise in particular was not commonly prescribed. This is an important omission as progressive aerobic exercise is increasingly recognised as a key intervention in improving outcomes2. 

We strongly advocate against extrapolating the findings of PD-REHAB to all patients with Parkinson's disease.  This approach would neglect to take into consideration the increasing number of high quality trials that report significant benefit of physiotherapy intervention in hard outcomes such as falls3–5.  Whilst the exact timing, volume and nature of occupational and physiotherapy remains to be delineated, there are increasing numbers of high quality trials in this area.  We recognise the need to develop outcome measures that can better reflect the diverse range of activities that occupational therapists use with patients.  Careful consideration should be given to the enrolment criteria and intervention that was delivered in PD-REHAB and these negative findings should be interpreted in conjunction with the broader evidence base.  

Dr E Henderson, Dr R Skelly, Dr R Genever, Dr J Liddle, , Dr P Fletcher, Prof R Walker, Dr S Evans, Dr V Lyell, Dr T Jones, Dr J Fisher, Dr A-L Cunnington, Dr V Haunton, Dr I Leroi, on behalf of the British Geriatric Society Movement Disorder Section (BGS-MDS).

1. Clarke, C. E. et al. Physiotherapy and Occupational Therapy vs No Therapy in Mild to Moderate Parkinson Disease. JAMA Neurol. 1–9 (2016). doi:10.1001/jamaneurol.2015.4452
2. Ahlskog, J. E. Does vigorous exercise have a neuroprotective effect in Parkinson disease? Neurology 77, 288–294 (2011).
3. Li, F. et al. Tai Chi and Postural Stability in Patients with Parkinson’s Disease. N Engl J Med 366, 511–519 (2013).
4. Morris, M. E. et al. A Randomized Controlled Trial to Reduce Falls in People With Parkinson’s Disease. Neurorehabil. Neural Repair 29, 777–785 (2015).
5. Canning, C. G. et al. Exercise for falls prevention in Parkinson disease: a randomized controlled trial. Neurology 84, 304–312 (2015)