Review
Effectiveness of multidisciplinary interventions to improve the quality of life for people with Parkinson's disease: A systematic review

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Abstract

Aims

To conduct a systematic review and critically evaluate the literature on the effectiveness of multidisciplinary interventions to improve quality of life for people with Parkinson's disease.

Methods

An electronic search of the following publication databases was performed for records from 1995 to 2011: CINAHL PLUS (EBSCO), Joanna Briggs Institute, Pubmed, Web of Science (ISI), psycINFO, Scopus and Cochrane library. The keywords used were Parkinson's disease, nursing, allied health, doctor, intervention, quality of life, rehabilitation, multidisciplinary team and their various combinations. Key terms were matched to MeSH subject headings and exploded where relevant to include all subheadings and related terms to each key term used. 1808 articles were initially identified based on our selection criteria and the reference list of these articles was hand searched. Nine studies were included after this sifting process and critiqued by two reviewers.

Results

Three randomised controlled trials and 6 non-randomised cohort studies were included. For these studies the level of evidence ranged from the Scottish Intercollegiate Network (SIGN) level of 1- to 2-. The outcome measures assessed were heterogeneous, including measures of disability of disease, stage of disease and various quality of life measures.

Conclusion

The evidence quantifying positive and sustained effects of multidisciplinary interventions to improve quality of life for people with Parkinson's disease is inconclusive. There has been relative lack of controlled experimentation to quantify therapy outcomes. The studies reviewed were varied and lacked long-term follow-up to quantify retention of the intervention. It is recommended that interventions to improve quality of life are tested in randomised controlled trials using standardised outcome measures, adequately powered samples and longer follow-up periods to assess intervention sustainability.

Introduction

Parkinson's disease (PD) is a complex, slowly progressive, neurodegenerative neurological condition characterised by bradykinesia, tremor, rigidity and impairment of postural reflexes (Lang and Lozano, 1998). PD is a common disorder that affects an estimated four million people worldwide and is expected to double by the year 2030 (Dorsey, 2007). This highlights the growing global burden of PD.

PD causes motor disabilities, problems with gait and balance that increase the risk of falls and injuries, and problems with swallowing and speech (Morgan and Sethi, 2007). Motor complications, especially nocturnal akinesia and levodopa-induced dyskinesia, reduce the health-related quality of life (HRQoL) of people with PD (Chapuis et al., 2005). Quality of life (QoL) has been defined as ‘an individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ (WHOQOL, 1995). Furthermore with respect to health-related quality of life (HRQoL) it is generally agreed that the relevant aspects may vary from study to study but can include general health, physical functioning, physical symptoms and toxicity, emotional functioning, cognitive functioning, role functioning, social well-being and functioning, sexual functioning and existential issues (Fayers and Machin, 2007). People with PD also experience a wide range of non-motor symptoms including disorders of the sleep–wake cycle, postural hypotension and a variety of alterations in mood, initiative and cognitive functioning (Poewe, 2007). Studies have suggested that symptoms affecting the person with PD's ability to function and cope psychosocially are the worst facet of PD (Schenkman et al., 2002). In addition, there were many reports on the negative impact of PD on the quality of life of patients and their caregivers (Behari et al., 2005, Caap-Ahlgren and Dehlin, 2002, Hobson et al., 1999). Furthermore, depression can worsen PD symptoms and the patient's ability to manage activities of daily living (Kuhn et al., 1996, Starkstein et al., 1992). Neuropsychiatric disturbances often occur in people with PD (Aarsland et al., 1999) and contribute considerably to their reduced quality of life (Karlsen et al., 2000).

The wide-ranging motor and non-motor effects of PD present people with PD and their caregivers with the ongoing challenge of managing the consequences of disease progression. While medications and surgical treatments can improve symptoms, there is still no known cure for the disease (Steindler, 2005). In the early stages of PD, medication enables patients to remain functionally independent (Jankovic, 2000). As the disease progresses, medication treatment becomes less effective to the stage where full time caregiving is required (Martinez-Martin et al., 2008). Non-pharmacological approaches to the management of PD are well acknowledged as part of an integrated treatment plan. Currently, there is a trend towards providing multidisciplinary PD interventions (Gage and Storey, 2004). In order to gain an understanding of whether multidisciplinary interventions are effective in improving the quality of life for people with PD, a systematic review of the available literature was performed.

Section snippets

Aims

The research question for this systematic review is “Are multidisciplinary interventions to improve the quality of life of people with PD more effective than the conventional disciplinary approach?”

The aims of this systematic review were:

  • 1.

    To review and critically evaluate the literature on the effectiveness of multidisciplinary interventions in improving quality of life for people with PD.

  • 2.

    To determine whether multidisciplinary interventions are more effective in improving quality of life than

Search strategy

An electronic search of the following publication databases was performed in November 2007 and updated in March 2011: CINAHL PLUS (EBSCO), Joanna Briggs Institute, Pubmed, Web of Science (ISI), psycINFO, Scopus and Cochrane library using the keywords (Table 1) and their various combinations. Key terms were matched to MeSH subject headings and exploded (exp) where relevant to include all subheadings and related terms to each key term used. Terms were searched as keywords (mp) when there were no

Results

Nine studies with trials on multidisciplinary interventions for people with PD were included as shown in Table 2. The interventions were mostly conducted in Europe and included a six-week outpatient multidisciplinary educational programme; a multidisciplinary programme of education plus rehabilitation; and an individually adapted multidisciplinary rehabilitation programme. As illustrated in Table 2, the interventions were heterogeneous using different outcome measures.

Of the nine studies, five

Discussion

In order to provide a broader picture of the available evidence, studies that also did not provide strong levels of evidence were included in this review. However, reviewed studies were found to be heterogeneous in design and outcomes. The major issues in the reviewed studies were a lack of information regarding levodopa intake, a lack of long-term follow-up to quantify persistence of the intervention and heterogeneous outcome measures. Therefore there was no standardised way of measuring the

Implications for future research

Recommendations for future research are the design of randomised controlled trials to test interventions with standardised outcome measures. Such trials should include a longer follow-up period (e.g. 6, 12, 24 months) to assess the sustained benefits of intervention on quality of life. All studies should measure the levodapa daily equivalent as it is a major confounding factor. The intervention should preferably be an ongoing programme as care for people with PD is long term and needs increase

Conclusion

Evidence quantifying positive and sustained effects of multidisciplinary interventions to improve the quality of life for people with PD is inconclusive. There has been an relative lack of controlled experimentation to quantify therapy outcomes. The studies reviewed were heterogeneous and generally lacked long-term follow-up to quantify retention of intervention. Until large-scale RCTs have been conducted, clinicians will have to continue to rely on expert opinion, their own clinical

Authors’ contribution

Siok Bee Tan – Design, Literature search, sifting process and critique of articles, meta-analysis, writing first draft of manuscript.

Allison Williams – Design, manuscript review and critique.

David Kelly – Literature search, sifting process and critique of articles, manuscript review and critique.

Acknowledgements

We would like to thank Dr Edwin Chan (Statistician) for his statistical assistance in this review

Conflict of interest: None declared.

Funding: None.

Ethical approval: Not applicable.

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