Clinical Practice Guideline For The Physical Therapist . - Apta

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CLINICAL PRACTICE GUIDELINE FOR THE PHYSICAL THERAPIST MANAGEMENT OF PARKINSON DISEASE Please cite this guideline as: American Physical Therapy Association. Clinical Practice Guideline for the Physical Therapist Management of Parkinson Disease URL . Published Publication Date 1

Disclaimer This clinical practice guideline was developed by an American Physical Therapy (APTA) volunteer guideline development group consisting of physical therapists and a neurologist. It was based on systematic reviews of current scientific literature, clinical information, and accepted approaches to the physical therapist management of Parkinson disease. This clinical practice guideline is not intended to be a fixed protocol, as some patients may require more or less treatment. Clinical patients may not necessarily be the same as participants in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances. Disclosure Requirement In accordance with APTA policy, all individuals whose names appear as authors or contributors to this clinical practice guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this clinical practice guideline. Funding Source This clinical practice guideline was funded exclusively by APTA, which received no funding from outside commercial sources to support its development. Copyright All rights reserved. No part of this clinical practice guideline may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from APTA. If you wish to request permission, please contact: Published 2021 by the American Physical Therapy Association 3030 Potomac Ave., Suite 100 Alexandria, VA 22305 First Edition 2021 by the American Physical Therapy Association 2

Table of Contents Table 1. Summary of Recommendations . 6 AEROBIC EXERCISE . 6 RESISTANCE TRAINING . 6 BALANCE TRAINING . 6 FLEXIBILITY EXERCISES . 6 EXTERNAL CUEING . 6 COMMUNITY-BASED EXERCISE . 7 GAIT TRAINING . 7 TASK-SPECIFIC TRAINING . 7 BEHAVIORAL CHANGE APPROACH . 7 INTEGRATED CARE . 7 TELEREHABILITATION . 7 SUMMARY OF BEST PRACTICE STATEMENTS . 8 DEEP BRAIN STIMULATION . 8 EXPERT CARE. 8 GUIDELINE DEVELOPMENT GROUP ROSTER . 9 Introduction . 10 Overview. 10 Goals and Rationale . 10 Intended Users . 10 Patient Population . 11 Burden of Disease . 11 Etiology . 11 Risk Factors . 12 Potential Benefits, Risks, Harms, and Costs . 12 Emotional and Physical Impact . 12 Future Research. 12 Methods . 12 Best Evidence Synthesis . 13 Literature Searches . 13 Defining the Strength of the Recommendations . 13 Patient Involvement. 13 Voting on the Recommendations . 13 3

Structure of the Recommendations. 13 Role of the Funding Source . 14 Table 2. Rating the Quality of Evidence . 14 Table 3. Magnitude of Benefits, Risks, Harms, and Costs . 15 Table 4. Strength of Recommendations . 15 Table 5. Linking the Strength of Recommendation, Quality of Evidence, Rating of Magnitude, and Preponderance of Risk vs. Harm to the Language of Obligation . 16 Peer Review and Public Commentary . 17 Study Attrition Flowchart . 18 RECOMMENDATIONS . 19 AEROBIC EXERCISE . 19 RESISTANCE TRAINING . 22 BALANCE TRAINING . 27 FLEXIBILITY EXERCISES . 32 EXTERNAL CUEING . 34 COMMUNITY-BASED EXERCISE . 38 GAIT TRAINING . 42 TASK-SPECIFIC TRAINING . 48 BEHAVIOR-CHANGE APPROACH . 53 INTEGRATED CARE . 56 TELEREHABILITATION . 60 BEST-PRACTICE STATEMENTS . 62 DEEP BRAIN STIMULATION . 62 EXPERT CARE. 63 NON-RECOMMENDATIONS . 63 Revision Plans . 64 Dissemination Plans. 64 Appendix 1 . 65 References for Included Literature. 65 Appendix 2 . 85 Excluded Literature . 85 Guideline Development Group Disclosures . 120 Appendix 3 . 121 PICO Questions Used to Define Literature Search . 121 Literature Search Strategy . 122 4

Inclusion Criteria. 125 References . 126 5

1 2 Table 1. Summary of Recommendations 3 AEROBIC EXERCISE 4 5 6 7 8 Physical therapists should implement moderate- to high-intensity aerobic exercise to improve oxygen consumption (V02), reduce motor disease severity, and improve functional outcomes in individuals with Parkinson disease. Evidence Quality: High Recommendation Strength: Strong 9 10 RESISTANCE TRAINING 11 12 13 Physical therapists should implement resistance training to reduce motor disease severity, and improve strength, power, nonmotor symptoms, and functional outcomes, and quality of life in individuals with Parkinson disease. 14 15 Evidence Quality: High Recommendation Strength: Strong 16 BALANCE TRAINING 17 18 19 20 21 22 Physical therapists should implement balance-training intervention programs to reduce postural control impairments, and improve balance and gait outcomes, mobility, balance confidence, and quality of life in individuals with Parkinson disease. 23 Evidence Quality: High Recommendation Strength: Strong 24 FLEXIBILITY EXERCISES 25 26 Physical therapists may implement flexibility exercises to improve range of motion (ROM) in individuals with Parkinson disease. 27 28 Evidence Quality: Limited Recommendation Strength: Weak 29 30 EXTERNAL CUEING 31 32 33 34 35 Physical therapists should implement external cueing to reduce motor disease severity and freezing of gait, and to improve gait outcomes in individuals with Parkinson disease. Evidence Quality: High Recommendation Strength: Strong 36 37 38 6

39 COMMUNITY-BASED EXERCISE 40 41 42 Physical therapists should recommend community-based exercise to reduce motor disease severity, and improve nonmotor symptoms, functional outcomes, and quality of life in individuals with Parkinson disease. 43 44 Evidence Quality: High Recommendation Strength: Strong 45 GAIT TRAINING 46 47 48 49 50 Physical therapists should implement gait training to reduce motor disease severity, and improve stride length, gait speed, mobility, and balance in individuals with Parkinson disease. 51 Evidence Quality: High Recommendation Strength: Strong 52 TASK-SPECIFIC TRAINING 53 54 55 56 57 Physical therapists should implement task-specific training to improve task-specific impairment levels and functional outcomes for individuals with Parkinson disease. Evidence Quality: High Recommendation Strength: Strong 58 59 BEHAVIOR-CHANGE APPROACH 60 61 Physical therapists should implement behavior-change approaches to improve physical activity and quality of life in individuals with Parkinson disease. 62 63 Evidence Quality: High Recommendation Strength: Moderate 64 65 INTEGRATED CARE 66 67 Physical therapist services should be delivered within an integrated care approach to reduce motor disease severity and improve quality of life in individuals with Parkinson disease. 68 69 70 Evidence Quality: High Strength of Recommendation: Strong 71 TELEREHABILITATION 72 73 Physical therapist services may be delivered via telerehabilitation to improve balance in individuals with Parkinson disease. 74 75 Evidence Quality: Moderate Recommendation Strength: Weak 7

76 77 78 SUMMARY OF BEST-PRACTICE STATEMENTS The following recommendations are consensus statements by the guideline development group based on current clinical practice norms and clinical expertise. 79 DEEP BRAIN STIMULATION 80 81 82 In the absence of reliable evidence, the opinion of the guideline development group is that more research is needed on the effects of physical therapist interventions in individuals undergoing deep brain stimulation. 83 Recommendation Strength: Best practice 84 EXPERT CARE 85 86 87 In the absence of reliable evidence, the opinion of the guideline development group is that physical therapist services delivered by physical therapists with expertise in Parkinson disease may result in improved outcomes compared with services provided by those without expertise. 88 Recommendation Strength: Best practice 89 90 91 8

92 GUIDELINE DEVELOPMENT GROUP ROSTER 93 94 95 96 97 98 Voting Members Terry Ellis, PT, PhD, FAPTA Co-Chair; American Physical Therapy Association, American Parkinson's Disease Association 110 Justin Martello, MD 111 American Academy of Neurology Sujata Pradhan, PT, PhD American Physical Therapy Association 99 Jacqueline Osborne, PT, DPT 100 Co-Chair; American Physical Therapy 101 Association 112 113 114 115 116 102 Rachel Botkin, PT, MPT 103 American Physical Therapy Association 117 Janet Readinger, PT, DPT 118 American Physical Therapy Association 104 Cristina Colón-Semenza, PT, MPT, PhD 105 American Physical Therapy Association 119 Tami Rork DeAngelis, PT, MPT 120 American Parkinson’s Association 121 106 Oscar Gabriel Gallardo, PT, DPT 107 American Physical Therapy Association 108 Abigail Leddy Whitt, PT, DPT 109 American Physical Therapy Association Miriam Rafferty, PT, DPT, PhD American Physical Therapy Association 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 APTA/AAOS Staff 1. 2. 3. 4. 5. 6. 7. 8. 9. Anita Bemis-Dougherty, PT, DPT, MAS, Vice President, Practice, APTA Heidi Kosakowski, PT, DPT, PhD, Senior Practice Specialist, APTA Jayson Murray, MA, Director, Department of Clinical Quality and Value, AAOS Danielle Schulte, MS, Manager, Department of Clinical Quality and Value, AAOS Nicole Nelson, MPH, Manager, Department of Clinical Quality and Value, AAOS Jenna Saleh, MPH, Research Analyst, Department of Clinical Quality and Value, AAOS Kaitlyn Sevarino, MBA, Senior Manager, Department of Clinical Quality and Value, AAOS Tyler Verity, Medical Librarian, Department of Clinical Quality and Value, AAOS Jennifer Rodriguez, Quality Development Assistant, Department of Clinical Quality and Value, AAOS 138 139 9

140 Introduction 141 142 143 144 145 146 Overview 147 148 149 This CPG is intended to be used by all qualified and appropriately trained physical therapists and physical therapist assistants involved in the management of individuals with PD. It also is intended to be an information resource for decision makers, health care providers, and consumers. 150 151 152 153 154 155 156 157 158 Goals and Rationale 159 160 161 162 163 164 165 166 167 Neurological care is provided in diverse settings by many different providers. This CPG is an educational tool to guide qualified clinicians through a series of treatment decisions in an effort to improve quality and efficiency and reduce unwarranted variation of care. Recommendations guide evidence-based practice while considering the patient’s wants and needs in the clinical decision-making process. This CPG should not be construed as including all proper methods of care or excluding methods of care reasonably directed at obtaining the same results. The ultimate judgment regarding the application of any specific procedure or treatment must be made in light of all circumstances presented by the patient, including safety, preferences, and disease stage, as well as the needs and resources particular to the locality or institution. 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 Intended Users This clinical practice guideline (CPG) is based on a systematic review of published studies involving the physical therapist management of individuals with Parkinson disease (PD). In addition to providing practice recommendations, this guideline also highlights limitations in the literature, areas that require future research, intentional vagueness, and potential benefits, risks, harms, and costs to implementing each recommendation. The purpose of this CPG is to help improve the physical therapist management of individuals with Parkinson disease based on the current best evidence. Current evidence-based practice standards demand that clinicians use the best available evidence in their clinical decision-making, incorporate clinical expertise, and consider the patient’s wants and needs. To assist clinicians, this CPG contains a systematic review of the available literature regarding the management of individuals with PD. This review included randomized controlled trials published between January 1, 1994, and June 16, 2020, and identifies where there is strong evidence, where evidence is lacking, and topics that future research must target to improve the management of individuals with PD. This CPG is intended to be used by physical therapists, and physical therapist assistants under the direction of physical therapists, for the management of individuals with Parkinson disease. Physical therapists are health care professionals who help individuals maintain, restore, and improve movement, activity, and functioning to enable optimal performance and enhance health, well-being, and quality of life. Neurologists, adult primary care clinicians, geriatricians, rehabilitation medicine provider, nurse practitioners, physician assistants, occupational therapists, speech language pathologists, and other health care professionals who routinely see patients with PD in various practice settings also may benefit from this guideline. This guideline is not intended for use as an insurance benefit determination document. Care for individuals with PD is based on decisions made by them in consultation with their health care team, which may comprise movement disorder specialists, general neurologists, geriatricians, primary care physicians, nurses, physical therapists, occupational therapists, speech language pathologists, registered dieticians, social workers and other professionals. Care includes medical and pharmacological 10

183 184 185 186 187 188 189 management and consideration of quality indicator guidelines such as those from the American Academy of Neurology (AAN).1 190 191 192 193 194 195 Patient Population 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 Burden of Disease 223 224 225 226 227 Etiology Once the individual (or advocate) has been informed of the nature of the available therapies and their rationale, duration, benefits, risks, costs, and has discussed the options with their health care provider, an informed and shared decision can be made. This CPG addresses the management of adult idiopathic, typical Parkinson disease. It is not intended to address management of individuals with atypical Parkinsonism disorders or other neurodegenerative conditions. Most studies reviewed include individuals in the early to mid-stages of PD as measured by Hoehn & Yahr (H&Y) stages 1-3.2 Recommendations may not generalize to those in the advanced H&Y stages 4-52 of the disease. As of 2017, over 1 million (1.04) people in the United States have been diagnosed with PD, and that number is expected to increase to nearly 1.64 million in 20 years.3 Ninety-one percent of these individuals were over the age of 65 and eligible for Medicare, and 54% were men.3 Globally, PD is the fastest growing of all neurological disorders, with a prevalence of 6.1 million, which is projected to increase to over 12 million worldwide by 2050.4 The total U.S. economic burden of PD was estimated to be 51.9 billion in 2017, with 25.4 billion representing direct medical costs and 26.5 billion representing indirect and nonmedical costs including premature death and lost employment of people with PD and their care partners.3 In 20 years, the total U.S. economic burden of the disease is estimated to be 79.1 billion.3 The average direct medical cost in 2017 for a person with PD eligible for Medicare was nearly 25,000.3 The average combined economic loss of a person with PD and their care partner was nearly 25,600 in 2017, for an aggregate total economic impact of over 50,000 per year.3 In the U.S., people with PD are hospitalized 1.44 times more than those without the disease and experience rehospitalization at a higher rate.5 In addition, during hospitalization, people with PD experience worsening symptoms and a decline in functional status that is below their baseline ability.5 A review of the literature indicates that there is a higher prevalence of PD among White and Hispanic populations globally than among those of African or Asian descent.6 In the U.S., the incidence of PD by race is difficult to isolate from disparities in health care utilization affecting the actual occurrence of PD among different ethnic groups.7 Therefore it is unclear if there is a biological basis that might explain the lower prevalence among those of African Americans or if this is due to disparities in health care utilization. Community-based studies that allow for a direct comparison of ethnic groups to determine disease prevalence and economic impact by race or ethnicity are currently not available. However, it has been found that allied health utilization is lower in African American and Hispanic individuals compared with Caucasian individuals with PD.8 Therefore, understanding this impact is an important area for future research to provide insight into disparities that exist between groups in terms of access to health carerelated resources. The etiology of PD is unknown.9 The degree to which environmental hazards, genetic susceptibility, head injury, or sedentary lifestyle contribute to the development of PD is not well understood. This diversity in the potential cause or causes of this disease leads to extensive variation in motor and nonmotor symptoms that affects both the central nervous system and many peripheral tissues in the body.9 11

228 229 230 231 232 233 234 235 236 237 Risk Factors 238 239 240 Potential Benefits, Risks, Harms, and Costs 241 242 243 244 245 Emotional and Physical Impact 246 247 Future Research 248 249 250 251 252 253 Methods 254 255 256 257 258 259 260 261 This CPG evaluates the effectiveness of approaches in the physical therapist management of Parkinson disease. APTA sought out the expertise of the AAOS Evidence-Based Medicine Unit as paid consultants to assist in the methodology of this CPG. The guideline development group (GDG) consisted of physical therapist members from APTA and its representative sections and academies, AAOS, the American Parkinson’s Disease Association, and a neurologist from the American Academy of Neurology. All GDG members, APTA staff, and methodologists were free of potential conflicts of interest relevant to the topic under study, as recommended by the National Academies of Sciences and Medicine’s Clinical Guidelines We Can Trust.15 262 263 264 265 266 267 268 269 This CPG was prepared by the APTA Parkinson Disease Clinical Practice Guideline Development Group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Department (methodologists). To develop this guideline, the GDG held an introductory meeting on April 4, 2019, to establish the scope of the CPG. The GDG defined the scope of the CPG by creating PICOT questions (eg, population, intervention, comparison, outcome, and time) that directed the literature search. The AAOS medical librarian created and executed the search (see Appendix 3 for search strategy). AAOS appraised the included randomized controlled trial studies and performed quality assessments based on the published guideline methodology. The GDG performed final reviews of the literature and created the Because the disease etiology is not well understood, relevant risk factors that influence the development of the disease are difficult to determine. Age is a known risk factor for disease development and peaks around age 80.9 Men and those of Hispanic origin develop the disease at higher rates than do women or those of other ethnicities.9 Environmental risk factors such as pesticide or herbicide exposure, prior head injury, β-blocker use, rural living, agricultural occupation, and well-water drinking have been linked to the development of the disease, while other environmental risk factors such as tobacco, caffeine, physical activity, NSAIDs, calcium channel blockers, and alcohol have been associated with a reduced risk of developing the disease.9, 10 Additionally, at least 23 loci or genetic locations have been identified as causing symptoms related to PD.11 The potential benefits, risks, harms, and costs are provided for each recommendation within this document. Disease duration in those diagnosed with PD can span decades.4 Due to the progressive nature of the disease, there is considerable emotional, social, and physical impact. These impacts include compromised functional status and quality of life, social isolation due to the presence and severity of motor and nonmotor symptoms, and increased burden on care partners.12 Consideration for future research is provided for each recommendation within this document. The methods used to develop this CPG were employed to minimize bias and enhance transparency in the selection, appraisal, and analysis of the available evidence. These processes are vital to the development of reliable, transparent, and accurate clinical recommendations for physical therapist management of Parkinson disease. Methods from the APTA Clinical Practice Guideline Manual13 and AAOS Clinical Practice Guideline Methodology14 were used in development of

This clinical practice guideline was developed by an American Physical Therapy (APTA) volunteer guideline development group consisting of physical therapists and a neurologist. It was based on systematic reviews of . management and consideration of quality indicator guidelines such as those from the American 184 . Academy of Neurology (AAN). 1.

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