Multidisciplinary care for patients with Parkinson's disease

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Summary

Parkinson's disease (PD) is a chronic and progressive neurodegenerative disorder with a complex phenotype, featuring a wide variety of both motor and non-motor symptoms. Current medical management is usually monodisciplinary, with an emphasis on drug treatment, sometimes supplemented with deep brain surgery. Despite optimal medical management, most patients become progressively disabled. Allied health care may provide complementary benefits to PD patients, even for symptoms that are resistant to pharmacotherapy or surgery. This notion is increasingly supported by scientific evidence. In addition, the role of allied health care is now documented in recent clinical practice guidelines that are available for physiotherapy, occupational therapy and speech-language therapy. Unfortunately, adequate delivery of allied health care is threatened by the insufficient expertise among most therapists, and the generally low patient volumes for each individual therapist. Moreover, most allied health interventions are used in isolation, with insufficient collaboration and communication with other disciplines involved in the care for PD patients. Clinical experience suggests that optimal management requires a multidisciplinary approach, with multifactorial health plans tailored to the needs of each individual patient. Although the merits of specific allied health care interventions have been scientifically proven for other chronic disorders, only few studies have tried to provide a scientific basis for a multidisciplinary care approach in PD. The few studies published so far were not yet convincing. We conclude by providing recommendations for current multidisciplinary care in PD, while highlighting the need for future clinical trials to evaluate the cost-effectiveness of a multidisciplinary team approach.

Introduction

Parkinson's disease is a chronic and progressive neurodegenerative disorder with a complex and diverse phenotype. Clinically discernable motor features include varied combinations of resting tremor, akinesia, rigidity, gait impairment and postural instability. In addition, most patients also experience a wide variety of non-motor symptoms, including neuropsychiatric complaints (depression, anxiety or cognitive decline), sleep disorders, autonomic dysfunction and sensory problems. These non-motor symptoms have a major impact on the quality of life and are an important source of disability.

Section snippets

Current medical management

The current therapeutic approach of PD is often ‘monodisciplinary’, i.e. only one medical discipline is involved in the care for patients. In most cases this is the medical specialist (neurologist or geriatrician) who focuses on minimising motor symptoms and reducing disease severity. Therapy is based primarily on symptomatic treatment with dopaminergic medication, and this is usually effective in reducing the classical motor features. However, there are drawbacks to current pharmacotherapy in

Allied health care

Allied health care may complement these standard medical treatments, both in terms of focus, treatment goals and working mechanisms (Table 1). Allied health care includes physiotherapy (PT), occupational therapy (OT) and speech-language therapy (SLT), as well as treatment by dieticians, social workers or sexologists. While the neurologist determines disease severity and optimizes medical treatment to reduce symptoms, allied health therapists aim to minimize the impact of the disease process and

Multidisciplinary treatment of PD

Given the complexity of PD, a multidisciplinary approach would appear to be preferable. Indeed, allied health care interventions are effective for only part of the complex symptom spectrum in PD. A multidisciplinary team approach, combining pharmacological and non-pharmacological therapies, thus seems necessary to obtain optimal therapeutic efficacy. For this reason (and also increasingly driven by patient foundations), specialized PD centres have begun to implement integrated and

Evidence for multidisciplinary care in PD (and beyond)

Multidisciplinary care is used increasingly, but the question arises how well founded this approach is. Scientific evidence on the effectiveness of multidisciplinary care in PD is limited. Positive effects on health, disability, quality of life and well-being have been reported in several uncontrolled studies that used a pre-test versus post-test design [22, 23, 24, 25]. Only few studies used a controlled design to evaluate the effectiveness of multidisciplinary care in PD [26, 27]. One

Future trials

Although sound scientific evidence is available for certain allied health care interventions, the evidence for an integrated multidisciplinary approach is still limited. Clearly, more work is needed to substantiate the general feeling that multidisciplinary care improves the quality of care and leads to a better outcome for patients. Research is needed to provide a more thorough basis for multidisciplinary care in PD (in case of positive findings), or to a critical reappraisal of this costly

Conflict of interests

The authors have no conflicts of interest to report.

Acknowledgements

M.A. van der Marck was supported by the National Parkinson Foundation, ‘Stichting Nuts-Ohra’ and ‘Stichting Porticus’. Prof. B.R. Bloem, MD, PhD was supported by a ZonMw VIDI research grant (number 016.076.352).

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