NeuroVoices: Michael S. Okun, MD, on the Potential Benefit of Continuous Physical Therapy in Parkinson Disease


The national medical advisor for the Parkinson's Foundation discussed the importance of continuous and ‘spaced’ physical therapy for Parkinson disease, highlighting the underutilization of this approach.

Michael S. Okun, MD, national medical advisor for the Parkinson's Foundation

Michael S. Okun, MD

Credit: UF Health

Parkinson disease (PD) is a neurodegenerative disorder that results in progressive worsening of mobility deficits which may significantly impact a patient's quality of life. Physical therapy (PT) is commonly prescribed treatment in conjunction with pharmacotherapy to mitigate symptoms of PD. This form of treatment is prescribed as a ‘burst’ of short-term, closely spaced visits over 6 to 12 weeks, for neurological conditions.1 In a previously conducted 2022 study, data suggested that patients with PD may be more likely to maintain mobility when receiving spaced PT sessions over 6 months or longer compared with the same number of visits delivered in the traditional ‘burst’ schedule.2

In a newly published study as a follow-up, responses from 2 online surveys revealed a high prevalence of burst PT and variability in the acceptance of spaced PT.1 Conducted by senior author Michael S. Okun, MD, national medical advisor for the Parkinson's Foundation, and colleagues, these results shed light on the current landscape of practices for the disease, providing insight into the perspectives and behaviors of clinicians involved in the management of PD through PT. The sample of responses (n = 71) consisted of neurologists (n = 50, 70.4%), physical therapists (n = 7, 9.9%), researchers and research staff (n = 5, 7.0%), and other clinical roles (n = 9, 12.7%) from 55 unique sites.

Findings showed that over 90% of respondents reported that patients at their sites participated in burst PT while about half of respondents reported patients participated in spaced PT. Most respondents indicated that burst PT and spaced PT were either somewhat or very accepted (74.6% and 62.0%, respectively) when asked about accepted clinical practices for treating patients with PD. In addition, the most common timing of PT was 2 sessions per week in about half of the sites, followed by 1 session per week among 26.8% of sites.

In a new iteration of NeuroVoices, Okun, who also serves as the director of the Norman Fixel Institute for Neurological Diseases at University of Florida Health, spoke in a recent conversation about a proposed paradigm shift for PD therapy, distinguishing the type of care needed compared with other neurological conditions. He talked about how the underutilization of PT in PD impacts patient outcomes, according to the survey study. In addition, Okun spoke about the key role that physical therapists play in personalizing and adjusting therapy plans for patients with PD.

NeurologyLive: What was the objective of the study and what did you find in your conducted research?

Michael S. Okun, MD: The main premise is the way we are offering therapy for PD is somewhat flawed. PD is a disease of queueing, meaning the more that you queue and remind the brain and the system, the better. There are a lot of diseases like stroke or traumatic brain injury, for example, where we offer therapy for 6 or 8 weeks and then we stop it. PD is a disease of a group of systems in the brain called the basal ganglia. It's better to give the therapy in a more continuous and spaced way. Lead author Kelvin Au, MD, [assistant professor of neurology at the University of Kansas] of a randomized clinical trial we conducted looked at the benefits of this.2 We looked at how to maintain benefit by giving more continuous therapy over time in PD, which is a different type of paradigm when compared with other neurological diseases.

The other thing this current study points out is that we underutilized PT in PD even though there's evidence-based guidelines for it. It's hardly ever prescribed and studies that have looked at how often we use and prescribe therapy show about 10% to 15% of patients who have PD get prescribed the therapy. We're grossly underutilizing the resource. There are guidelines by the American Physical Therapy Association for how to give PD PT and how we give the therapy could make a difference. Frankly, we did a smaller trial and what we're aiming to do is larger scale studies to explore how important the timing is of the intervention.

Based on the results in this study, what can clinicians who see patients with PD consider?

In the United States, you don't need a prescription from a physician to get PT. You can go directly to a PT operation and request PT for your PD. That's important for patients to remember. Now, insurance companies may require you at some point to get a physician's endorsement on it, but in the United States physical therapists can provide directly. Physical therapists are experts in their field and they should be respected as experts, knowing how to administer the therapy and how to keep checking in to make sure you have the right plan to make sure you're having the right frequency and also to balance it with exercise therapy.

We know that daily exercise as well as stretching is good for PD. The physical therapist can help to guide and make sure that plan is appropriate, which is going to be different for patients because not everybody with PD has the same physical challenges. Patients may benefit in different ways. If you look at the American Physical Therapy published guidelines, they offer a whole list of different things that can be applied in specific situations. That’s why it's important. As we respect the expertise of a clinician to prescribe a drug, we should respect the expertise of physical therapists to prescribe the right therapy. We also make sure that patients are checking in with the physical therapist and clinician, to continue to ask questions such as “am I getting [PT] frequently enough? Does my plan need to be adjusted? Does my home exercise plan need to be adjusted?” These are really of paramount importance to success and maintenance of the beneficial effects of PT in PD.

Based on your study, what forward-thinking thoughts would you add?

It's shocking, the accessibility. PT is accessible, and it's not utilized. Even getting patients to a physical therapist with PD is one of the things we need to study to understand. We need to make sure more patients are benefiting because they're not getting the right therapy and the right plan, which is important. We need to study a lot more to know how to best personalize those plans, while understanding how heterogenous PD is. It's not a one size fits all. The combination of patients understanding they can access physical therapists without a prescription, that physical therapists are experts in their field and can help to guide them and that they need to continuously be checking in with their physicians [is important]. This includes checking in with their physical therapists to adjust the PT regimen, the exercise regimens, the stretching regimens, and adjusting these things over time because it's a dynamic disease.

The disease is changing. Changing with the disease can benefit not only the symptoms of PD, but hopefully the downstream benefits of prevention of things that can be devastating such as falls, fractures, hospitalizations, morbidity, and mortality. There can be a lot at stake for making sure the plan is good. Not only that, but it also can't just be, “I have a plan” like you have a New Year's resolution because you know what happens. You do that for a couple months, and then the next time the year comes around, you need to make a new year's resolution and try that one again. We've all done this.

In PD, a chronic progressive disease, what if I told you can keep the disease at bay and maintain your benefit by doing things on a regimen and on a schedule. That schedule and plan needs to be adjusted every few months by your physical therapist or physician or a combination of the 2 that you can be successful in meeting your benefit. I think if you have PD, that might be a very compelling message. That makes you think twice and perhaps act on getting a plan for the implementation of PT, with exercise, stretching and other modalities.

Transcript edited for clarity. Click here to view more NeuroVoices.

1. LeLaurin JH, Salloum RG, Okun MS. Current practices of burst vs. spaced physical therapy applied to Parkinson's disease. Parkinsonism Relat Disord. 2024;120:106022. doi:10.1016/j.parkreldis.2024.106022
2. Au KLK, Lopes JLMLJ, Kraus A, et al. A randomized clinical trial of burst vs. spaced physical therapy for Parkinsons disease. Parkinsonism Relat Disord. 2022;97:57-62. doi:10.1016/j.parkreldis.2022.02.021
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