Parkinson’s: NICE guidance

Jane Burridge and Ann Ashburn discuss the implications for physiotherapy of an updated national guideline on diagnosing and managing Parkinson’s

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Parkinson’s is a progressive neurological condition affecting one in 500 of the UK population. The condition is characterised by motor and non-motor symptoms resulting from reduced dopamine. Early problems such as loss of smell, joint pains or poor sleep may not immediately signal the condition but are often identified after diagnosis, which is made according to the UK Brain Bank criteria (bradykinesia and tremor or rigidity).

A shuffling pattern of walking with increased flexion of the hips and spine is characteristic of the condition with loss of plantar flexion at the ankle, reduced forces through the lower limbs and loss of heel strike during gait. Other factors that affect how individuals move, including freezing and impaired cognition and attention. One of the most disabling and common problems is falling: people with Parkinson’s are twice as likely to fall as the general older person. Balance and falls do not respond to medication.

We will now look at some of the key recommendations in guidance issued last year by the National Institute for Health and Care Excellence (NICE). See www.nice.org.uk/guidance/ng71

Recommendations

  1. Consider referring people who are in the early stages of Parkinson’s to a physiotherapist with experience of Parkinson’s for assessment, education and advice, including information about physical activity.
  • We support the recommendation that people with Parkinson’s should be referred, soon after diagnosis, to a physiotherapist with specialist knowledge of the condition for information, advice and treatment.
  • Following this guideline, more experts in the field are needed and although high-quality masterclasses are available across Europe, greater access to specialist training is required. Perhaps membership of a college of excellence would drive the specialism and the Association of Chartered Physiotherapists in Neurology should take on this role by contributing to the organisation, design and validation of multidisciplinary postgraduate courses for a team approach.
  • The benefits from exercises and strategy programmes among those with least severe disease severity and non-fallers have been highlighted by researchers.
  • Offer Parkinson’s disease-specific physiotherapy for people who are experiencing balance or motor function problems
    • We support this recommendation as a number of research studies has consistently found that exercises for balance and motor function provide benefits.
    • Outcome measures need to be sensitive to high levels of function for use with a range of abilities in research and clinical practice. We were surprised to see the Berg Balance Scale highlighted in the NICE guidelines as this has been shown to have a ceiling effect, unlike the Mini-Best test which has been recommended for use across the Parkinson’s spectrum. The ability to detect change at a high-functioning level is important in the light of recommendation 1.
    • There are problems related to Parkinson’s that are not mentioned in the guidelines that we believe merit further consideration in relation to function and movement. Fatigue, cognitive impairment and falls are features that are inevitably linked to people’s everyday activities. Guidelines on these are needed, along with knowledge of the psychosocial aspects of deteriorating conditions and the effects on the person and carers.
  • Consider the Alexander Technique for people with Parkinson’s who are experiencing balance or motor function problems.
    • We do not agree with this recommendation and challenge the strength of the supporting evidence for the Alexander Technique. The Self-assessment Parkinson’s Disease Disability Scale used in the 2002 paper referred to in the guideline relies in part on individuals’ perception of improvement in posture and balance, and counts numbers of people who change. Crucially, we believe, there were no objective measures of posture and balance.

    Jane Burridgeis professor of restorative neuroscience and Ann Ashburn is professor of rehabilitation, University of Southampton. Professor Burridge is the president of the Association of Chartered Physiotherapists in Neurology (ACPIN), a CSP professional network.

    Research recommendations

    Does physiotherapy started early in the course of Parkinson’s, as opposed to after the onset of motor symptoms, confer benefits in terms of delaying symptom onset and/or reducing the severity of symptoms?

    • We support this research question but recognise the difficulty and the cost of running longitudinal studies over several years in order to understand the outcome of early intervention.
    • More high-quality clinical trials are needed in the rehabilitation of people with Parkinson’s. Of the 38 trials considered in National Institute for Health and Care Excellence review, only two were included in the analysis of evidence because most failed the quality criteria.

    More information

    Association of Chartered Physiotherapists in Neurologywww.acpin.net
    A European physiotherapy guideline for Parkinson’s can be downloaded from www.parkinsonnet.info/guidelines This guideline was discussed in previous Clinical Update on Parkinson’s
    A CSP Physiotherapy Works briefing on Parkinson’s is also available on the CSP site. 

    Author
    Jane Burridge and Ann Ashburn

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