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 acces32763
1. Exploring physiotherapy for Parkinsonís 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
2. Background: The need for a clear definition of physiotherapy Physiotherapy is viewed as essential within the management of people with Parkinsonís 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 Parkinsonís UK (formally the Parkinsonís 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.
3. 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:
Inform the physiotherapy intervention delivered within the PD REHAB trial.
Promote equality in clinical practice
4. 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
5. Methods of the Delphi survey Design
A two round modified Delphi survey with additional closed-question questionnaire
Clinical physiotherapists or research physiotherapists with an interest/ expertise in the management of people with PD
Conducted from the University of Birmingham and disseminated to members of the Delphi panel via email
6. Design of the Delphi survey
7. 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
8. Findings from the optional questionnaire
9. 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 hadnít received post-graduate training would like to
10. 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
Therapy predominantly delivered in the patientís home or outpatient setting
11. 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)
12. Findings of the Delphi survey
13. Delphi survey: Reasons for physiotherapy
14. Delphi survey: Core areas of physiotherapy Consensus No Consensus
15. Delphi survey: Treatment within physiotherapy
16. Perceived effective treatment techniques: Gait Consensus
External cueing techniques (visual/ auditory/ sensory/ verbal prompts)
Cognitive movement strategies
Lower limb strengthening exercises
Joint mobility exercises
Functional walking practice (obstacles, turning etc)
Walking practice utilising patientís environment
Education and practice using walking aids
17. Perceived effective treatment techniques: Balance Consensus
Multifaceted, progressive exercise programmes
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)
18. 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
19. Perceived effective treatment techniques: Physical conditioning Consensus
Joint mobility/ flexibility exercises
Posture rehabilitation to support cardiorespiratory capacity
Recreational activity/ self-management
Referral to leisure facilities
Functional, task specific training
20. Perceived effective treatment techniques: Posture Consensus
Axial control and coordination exercises
Strengthening of the core muscles
Verbal and visual feedback
Passive and positional stretching
21. Perceived effective treatment techniques: Upper limb Consensus
Resistance and range of movement exercises
Upper limb coordination exercises
22. 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)
23. Outcome measurement
24. 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
25. Top outcome measures used in practice
Berg balance scale (43*)
Lindop PD assessment (26*)
10 metre walk (25*)
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
26. Conclusions Current services
Responding therapists were highly experienced in both years qualified and number of patients seen.
Physiotherapy is predominantly delivered in the patientís 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).
27. 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.
28. 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 Parkinsonís today Ė room for improvement. Results of the UKís largest ever survey of people with Parkinsonís 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.
29. Thank you