doi: 10.2522/ptj.

20070265
Originally published online April 24, 2008
2008; 88:812-819. PHYS THER.
DePiero, Anna D Hohler and Marie Saint-Hilaire
Terry Ellis, Douglas I Katz, Daniel K White, T Joy
Disease
Rehabilitation Program for People With Parkinson
Effectiveness of an Inpatient Multidisciplinary
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Effectiveness of an Inpatient
Multidisciplinary Rehabilitation
Program for People With
Parkinson Disease
Terry Ellis, Douglas I Katz, Daniel K White, T Joy DePiero, Anna D Hohler,
Marie Saint-Hilaire
Background and Purpose. In the outpatient setting, it can be difcult to
effectively manage the complex medical and rehabilitation needs of people with
Parkinson disease (PD). A multidisciplinary approach in the inpatient rehabilitation
environment may be a viable alternative. The purposes of this study were: (1) to
investigate the effectiveness of an inpatient rehabilitation program for people with a
primary diagnosis of PD, (2) to determine whether gains made were clinically
meaningful, and (3) to identify predictors of rehabilitation outcome.
Subjects. Sixty-eight subjects with a diagnosis of PD were admitted to an inpatient
rehabilitation hospital with a multidisciplinary movement disorders program.
Methods. Subjects participated in a rehabilitation program consisting of a com-
bination of physical therapy, occupational therapy, and speech therapy for a total of
3 hours per day, 5 to 7 days per week, in addition to pharmacological adjustments
based on data collected daily. A pretest-posttest design was implemented. The
differences between admission and discharge scores on the Functional Independence
Measure (FIM) (total, motor, and cognitive scores), Timed Up & Go Test, 2-Minute
Walk Test, and Finger Tapping Test were analyzed.
Results. An analysis of data obtained for the 68 subjects admitted with a diagnosis
of PD revealed signicant improvements across all outcome measures from admission
to discharge. Subjects with PD whose medications were not adjusted during their
admission (rehabilitation only) (n10) showed signicant improvements in FIM total,
motor, and cognitive scores. Improvements exceeded the minimal clinically impor-
tant difference in 71% of the subjects. Prior level of function at admission accounted
for 20% of the variance in the FIM total change score.
DiscussionandConclusion. The results suggest that subjects with a diagnosis
of PD as a primary condition beneted from an inpatient rehabilitation program
designed to improve functional status.
T Ellis, PT, PhD, NCS, is Clinical
Associate Professor, Department
of Physical Therapy and Athletic
Training, Sargent College of
Health and Rehabilitation Sciences,
Boston University, 635 Common-
wealth Ave, Boston, MA 02215;
Associate Director of Clinical Care,
Center for Neurorehabilitation, Bos-
ton, Mass; and Physical Therapist
and Clinical Research Scientist,
Braintree Rehabilitation Hospital,
Braintree, Mass. Address all cor-
respondence to Dr Ellis at: tellis@
bu.edu.
DI Katz, MD, is Associate Professor,
Department of Neurology, School
of Medicine, Boston University, and
Director, Brain Injury Program, De-
partment of Neurology, Braintree
Rehabilitation Hospital.
DK White, PT, ScD, NCS, is Post-
doctoral Research Fellow, Clinical
Epidemiology Research Training
Unit, School of Medicine, Boston
University.
TJ DePiero, MD, is Assistant Profes-
sor, Department of Neurology,
School of Medicine, Boston Uni-
versity, and Medical Director,
Stroke Program, Department of
Neurology, Braintree Rehabilita-
tion Hospital.
AD Hohler, MD, is Assistant Pro-
fessor, Department of Neurology,
School of Medicine, Boston Uni-
versity, and Staff Neurologist, De-
partment of Neurology, Braintree
Rehabilitation Hospital.
M Saint-Hilaire, MD, FRCPC, is As-
sistant Professor, Department of
Neurology, School of Medicine,
Boston University, and Medical Di-
rector of the Parkinson Disease Pro-
gram, Department of Neurology,
Braintree Rehabilitation Hospital.
[Ellis T, Katz DI, White DK, et al.
Effectiveness of an inpatient multi-
disciplinary rehabilitation program
for people with Parkinson disease.
Phys Ther. 2008;88:812819.]
2008 American Physical Therapy
Association
Research Report
Post a Rapid Response or
nd The Bottom Line:
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P
arkinson disease (PD) is a pro-
gressive neurological disorder
characterized by insidious on-
set. Despite pharmacological and
surgical interventions, people face a
relentless deterioration in mobility
and activities of daily living (ADL).
The clinical hallmarks of the disease
include rigidity, bradykinesia, tremor,
and loss of postural control. These
impairments lead to a decline in
functional status, so that people with
PD have difculty performing tasks
such as walking, rising from a chair,
and moving in bed. This decrease in
functional status often results in a
loss of independence and a decline
in quality of life (QOL).
Although a Cochrane review
1
of ran-
domized controlled trials (RCTs) re-
ported that there is insufcient evi-
dence to support or refute the
efcacy of physical therapy in PD, a
number of intervention studies have
found positive effects of physical
therapy in addition to medication
therapy (MT) in people with PD of
Hoehn and Yahr stage II or III. A
meta-analysis of 12 studies (RCTs and
quasi-experimental designs) investi-
gating the effects of physical therapy
in addition to MT in people with PD
demonstrated signicant summary
effect sizes with regard to ADL (0.40),
stride length (0.46), and walking
speed (0.49).
2
A meta-analysis of 16
studies investigating the effects of
occupational therapy for people with
PD revealed signicant summary ef-
fect sizes for outcomes classied at
the capabilities and abilities level
(0.5) and the activities and tasks
level (0.54).
3
A large-scale RCT (con-
ducted after the Cochrane review)
investigating the efcacy of physical
therapy plus MT interventions in
people with PD revealed signicant
differences between groups in the
areas of comfortable walking speed,
ADL, and QOL related to physical mo-
bility.
4
Effect sizes in this RCT were
consistent with those reported in the
2 meta-analyses described above.
The impact of rehabilitation may be
greater if implemented in an in-
patient setting. In the outpatient en-
vironment, it becomes increasingly
challenging to make optimal changes
in medication regimens with a brief
visit to the neurologist. Patients
symptoms become more complex
(dyskinesia, freezing, motor uctua-
tions, hallucinations, and loss of pos-
tural control) and difcult to manage
as the disease progresses. Observation
time is limited, and neurologists must
rely on patients reports for informa-
tion on the type, timing, and duration
of symptoms. The inpatient environ-
ment, however, may be a viable alter-
native in which selected patients with
a primary diagnosis of PD can receive
effective management when they ex-
perience more complex symptoms, a
decline in function, or frequent falls or
are in jeopardy of losing their indepen-
dence. With admission to an inpatient
multidisciplinary rehabilitation hospi-
tal, patients can participate in daily
therapies in an environment that al-
lows continuous monitoring of func-
tional status and medication response
by a team that is knowledgeable about
movement disorders. Although pa-
tients with PDoften are admitted to an
inpatient rehabilitation program fol-
lowing an orthopedic, cardiopulmo-
nary, or general medical procedure
(secondary diagnosis of PD), patients
with PD as the primary diagnosis are
not typically referred for inpatient
rehabilitation.
The purposes of this study were to
determine whether people with a di-
agnosis of idiopathic PD as a primary
condition showed improvements in
functional status following partici-
pation in a specialized inpatient
multidisciplinary rehabilitation pro-
gram and to determine whether the
improvements observed exceeded
the minimal clinically important dif-
ference (MCID). In addition, the sub-
group of people who did not have
medication adjustments during their
admission was analyzed separately
to examine changes attributable to
rehabilitation only. This study also
identied the determinants that best
predicted rehabilitation outcome.
We hypothesized that people with
PD would show statistically and clin-
ically signicant increases in func-
tional abilities following participa-
tion in an inpatient multidisciplinary
rehabilitation program administered
by a rehabilitation team with exper-
tise in movement disorders. We also
hypothesized that disease duration
and baseline functional status would
be important predictors of rehabili-
tation outcome.
Method
Design and Subjects
A pretest-posttest design was used to
evaluate the effectiveness of a move-
ment disorders program for subjects
who were admitted to an inpatient
rehabilitation hospital with a diagno-
sis of idiopathic PD. Subjects were
admitted to inpatient rehabilitation
from an acute care hospital, home, a
skilled nursing facility, or an assisted
living facility from January 2004 to
December 2006; were diagnosed
with typical idiopathic PD by a neu-
rologist specializing in movement
disorders, according to the United
Kingdom Parkinsons Disease Soci-
ety Brain Banks clinical diagnostic
criteria
5
; were at least 18 years of
age; and were classied as having PD
of Hoehn and Yahr stages I to V. A
total of 68 subjects who met these
criteria were admitted to the move-
ment disorders program. Baseline
characteristics of the subjects are
shown in Table 1.
Outcome Measures
The primary outcome measure used
to address the study aims was the
Functional Independence Measure
(FIM) total score.
6,7
Secondary out-
come measures were the FIM motor
score, the FIM cognitive score, the
2-Minute Walk Test (TMW),
8
the
Timed Up & Go Test (TUG),
9
and
the Finger Tapping Test (FT).
10
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The FIM is a widely used measure of
functional status developed speci-
cally for people in inpatient acute
care rehabilitation facilities. The FIM
comprises 2 sections: motor (13
items) and cognitive (5 items). These
items are rated with regard to the
performance of ADL tasks on a
7-point ordinal scale from a score of
1 (complete dependence) to a score
of 7 (independence), with a maxi-
mum possible total score of 126. The
FIM has well-established reliability
and validity as a generic instru-
ment.
6,7
It also has been shown to be
responsive to change following in-
tervention in people who have had a
stroke
11
but has not been studied in
people with PD.
The TMW is a safe, simple, and use-
ful measure of walking ability in peo-
ple with PD. Each subject was in-
structed to cover as much distance
as possible on foot in 2 minutes, be-
ing told, Keep walking until I tell
you to stop. A tester accompanied
the subject, acting as a timekeeper
and guarding as needed. Light and
colleagues
8
demonstrated that sub-
jects with PD walk a signicantly
shorter distance (X88 m [294 ft])
than sex- and age-matched control
subjects (X182 m [608 ft]).
The TUG is a quick test incorporat-
ing a transfer from a sitting position
to a standing position, ambulation,
and turning, which are frequently
impaired in people with movement
disorders.
9
Interrater reliability has
been demonstrated to be excellent
(intraclass correlation coefcient
.99) using the TUG in people with
PD.
12
The subjects were seated in a
chair with arms on the armrests and
were instructed to stand, walk
to a point 3 m (10 ft) away, turn
around, walk back to the chair, and
sit. One practice trial and one test
trial were recorded. The subjects
were allowed to use an assistive de-
vice if necessary. Normative values
for older people range from 10 to 11
seconds without a cane and from
11.5 to 15.2 seconds with a cane.
13
The FT was used to measure the
impact of common symptoms of
movement disorders (bradykinesia,
dyskinesia, and tremor) on upper-
extremity function. This measure
was used to determine the impact of
medication adjustments and rehabil-
itation on the upper extremities, par-
ticularly in subjects who were
nonambulatory and unable to partic-
ipate in other assessments. The FT
has been shown to be reliable and
valid.
10,14
Two buttons attached to
counters were mounted 30 cm apart.
The subjects alternated tapping of
the buttons with the left hand for 1
minute. The sum of the taps on both
buttons was the result for the left
hand. The test then was repeated
with the right hand.
Intervention
The program used in this study was a
comprehensive, specialized, inpa-
tient multidisciplinary rehabilitation
program. The aim of this program
was to optimize the subjects medi-
cation regimens and functional abili-
ties through a team approach. The
movement disorders team consisted
of a consulting neurologist with spe-
cialization in movement disorders,
attending neurologists (at the inpa-
tient rehabilitation facility) with spe-
cialization in neurorehabilitation, a
movement disorders fellow, physical
therapists, occupational therapists,
speech-language pathologists, nurses,
and case managers. Specic assess-
ment and treatment approaches were
developed for this movement disor-
ders program, and staff received reg-
ular in-service education on the
management of PD and movement
disorders.
In addition to the outcome measures
administered at admission and dis-
charge, daily measures (TMW, TUG,
and FT) were obtained at both the
peak and the trough times of the
medication cycle in order to capture
uctuations in a subjects status. Al-
though the same therapists adminis-
Table 1.
Baseline Characteristics and Discharge Status of Study Participants
Characteristic Value
Age, y, X (SD) 74.0 (8)
Disease duration, y, X (SD) 10.7 (7.4)
Sex, no. (%) men/women 30 (44)/38 (56)
Race, no. (%) white 66 (97)
Right-handedness, no. (%) 61 (90)
Education, no. (%) high school/high school 43 (63)/25 (37)
Hoehn and Yahr stage, no. (%) (n58)
I 0 (0)
II 1 (2)
III 18 (31)
IV 37 (64)
V 2 (3)
Level of function prior to admission, no. (%) (n58)
Physical assistance required 22 (38)
No physical assistance required 36 (62)
Discharge disposition, no. (%) discharged to home (n67) 47 (70)
Length of stay, d, X (SD) 20.8 (7.8)
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tered both the intervention and the
outcome measures, all therapy staff
involved in data collection partici-
pated in multiple training sessions in
order to standardize the administra-
tion of the outcome measures. Dur-
ing weekly walk rounds, the inter-
disciplinary team examined the data,
observed subject function, and dis-
cussed overall subject status. On
the basis of this information, deci-
sions regarding appropriate medica-
tion changes were made. An addi-
tional weekly movement disorders
team meeting was held to discuss
subjects responses to the medica-
tion adjustments and to examine ad-
ditional data points. Further changes
were made as needed, and this pro-
cess was continued until the subjects
were discharged.
Throughout their length of stay, sub-
jects participated in a combination
of physical therapy, occupational
therapy, and speech therapy for a
minimum of 3 hours per day, 5 to 7
days per week. Therapy was pro-
vided on an individual basis and in a
group format when appropriate. The
components of the intervention
were based on best evidence from
the literature.
15
These components
included the use of external cueing
to improve gait speed, step length,
and cadence
1618
; the application of
cognitive movement strategies to im-
prove bed mobility and transfers
19,20
;
balance training
21
; exercises to im-
prove joint mobility
22,23
and strength
(force-generating capacity)
24
; and
voice treatment to improve volume
and clarity of speech.
25,26
An over-
view of the components of the in-
tervention is shown in Table 2.
These components were individual-
ized to meet the needs of each study
participant.
Data Analysis
Means, standard deviations, and fre-
quency distributions were calculated
to describe subjects baseline char-
acteristics, length of stay, and dis-
charge disposition. The effectiveness
of the specialized inpatient multi-
disciplinary rehabilitation program
was evaluated by comparing admis-
sion and discharge mean scores on
each of the outcome measures de-
scribed above. Parametric statistics
were applied because the data for all
outcome measures were normally
distributed. Two-tailed paired t tests
were conducted with the alpha level
set at .05. A conservative Bonferroni-
adjusted type I error rate (.007)
was applied to all t tests. The effec-
tiveness of the program was investi-
gated for subjects who participated
in rehabilitation in addition to hav-
ing medication adjustments and for
subjects who participated in rehabil-
itation but whose PD medications
were not changed (rehabilitation
only) during their inpatient admis-
sion. In addition, the clinical signi-
cance of the improvements observed
was determined on the basis of the
FIM total change scores. An FIM total
change score of 22 has been
Table 2.
Description of the Intervention
Category Description
Functional training
a
Rolling from supine position to sitting position and from sitting position to supine position
Transferring from sitting position to standing position, from chair to bed, and from chair to toilet
Dressing and grooming
Balance: reactive and anticipatory within functional contexts
Gait training Walking with external auditory cues from a metronome to optimize gait speed and cadence;
increasing cadence by 10% over baseline and progressing until cadence approaches normal or
until subject reaches maximum capacity
Reducing freezing (context specic: doorways, thresholds, and narrow spaces) with visual cues in
the form of lines on the oor from tape or laser beams
Turning strategies (wide-arc)
Improving adaptation (various walking surfaces, obstacles in the environment, starting and
stopping, and turning head while walking)
Curb negotiation and stair climbing
Range-of-motion, exibility, and
strengthening exercises
Range of motion (increase trunk extension and rotation)
Stretching (hip exor, hamstring, and gastrocnemius muscles)
Strengthening (trunk and hip postural muscles and knee and ankle extensor muscles)
Speech exercises Exercises to improve vocal rate control
Exercises to improve phonation
a
Functional training consisted of multiple repetitions of task-specic practice conducted in a blocked fashion; complex movements were simplied into
subcomponents and practiced as whole tasks. Subjects actively sought solutions to meet the demands of these tasks.
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shown to be associated with the
MCID in people who have had a
stroke.
27
Therefore, in our study, a
change from baseline to discharge of
22 was considered clinically mean-
ingful, whereas a change of less than
22 was considered too small to be
clinically meaningful.
To determine the relationship be-
tween baseline indices (independent
variables) and treatment outcomes
(dependent variables), we conducted
a univariate analysis with Pearson
correlation coefcients. The following
factors served as predictor (inde-
pendent) variables: age, disease dura-
tion, sex, education level, Hoehn and
Yahr stage, prior level of function
(physical assistance required or not re-
quired for daily bed mobility, transfer
from sitting position to standing posi-
tion, and gait prior to admission, ac-
cording to subject or family report),
PD symptoms on admission (rigidity,
tremor, bradykinesia, postural instabil-
ity, dyskinesia, and speech and cogni-
tive impairments), and baseline status
on each of the outcome measures. The
dependent variable was FIM total
change score (discharge status minus
admission status). A stepwise regres-
sion analysis was conducted to iden-
tify which determinants identied as
signicant (P.20) in the univariate
analysis predicted rehabilitation out-
come. The signicance of each vari-
able entered into the regression analy-
sis was determined with a t test, the
signicance of R
2
was determined
with an F test, and the level of signi-
cance was set at .05. Colinearity diag-
nostics were applied for each variable
entered into the regression analysis in
order to control for unstable estimates
of entered regression coefcients. All
data analyses were performed with
SPSS Professional Statistics (version
15.0) software (for Windows).*
Results
All Subjects
An analysis performed on the entire
sample of subjects (N68) revealed
statistically signicant improvements
across all outcome measures from
admission to discharge (Tab. 3). The
FIM total score improved by a mean
of 31.5 (95% condence interval
[CI]28.035.1). The analysis also
revealed mean improvements of
27.7 (95% CI24.630.7) on the mo-
tor section of the FIM, 4.1 (95%
CI3.05.1) on the cognitive sec-
tion of the FIM, 21.0 m (69 ft)
(95% CI14.727.3) on the TMW,
19.8 seconds (95% CI8.730.8)
on the TUG, 19.2 nger taps (95%
CI13.425.0) on the left, and 20.1
nger taps (95% CI13.626.7) on
the right. The mean length of stay
was 20.8 days, with 47 (70%) of the
subjects being discharged to home.
Subjects Without
Medication Adjustments
For 10 of the 68 subjects who had
PD and who were admitted for reha-
bilitation, PD medications were not
adjusted. These subjects received
rehabilitation only. There were sta-
tistically signicant improvements
(P.007) in FIM total score, with
a mean increase of 32.0 (95%
CI23.440.6), in FIM motor score,
with a mean increase of 27.0 (95%
CI20.133.9), and in FIM cognitive
score, with a mean increase of 5.0
(95% CI2.27.8). The TUG scores
increased by a mean of 61.6 seconds
(95% CI14.3108.8), a nding that
approached statistical signicance
(P.017). The TMW and FT scores
did not reach statistical signicance.
Predictors of
Rehabilitation Outcome
Signicant correlations were found
between the FIM total change score
and prior level of function and be-
tween the FIM total change score
and the presence of dyskinesia on
admission. A lower prior level of
function and the presence of dyski-
nesia were associated with less im-
provement in the FIM total score.
Prior level of function accounted for
20% of the variance in the FIM total
change score (Tab. 3). The presence
of dyskinesia did not signicantly im-
prove model t.
MCID in the FIM Total Score
All subjects made gains in the FIM
total score, with a range of improve-
ments from 4 to 75. Forty-eight sub-
jects (71%) showed changes of 22
in the total FIM score, representing
clinically important differences (Fig-
ure). Eighty-three percent of the sub-
jects who did not require physical
assistance prior to admission experi-
enced clinically meaningful changes,
* SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.
Table 3.
Admission and Discharge Scores
Measure
a
(No. of Subjects)
X (SD) Score
b
at:
Admission Discharge
FIM total (68) 45.5 (13.7) 77.0 (18.6)
FIM motor (68) 27.1 (10.4) 54.8 (14.0)
FIM cognitive (68) 18.0 (5.6) 22.1 (5.8)
TMW, m (59) 54.6 (38.4) 75.6 (33.8)
TUG, s (58) 49.9 (44.8) 30.1 (24.1)
FT, left (47) 64.9 (24.5) 84.1 (24.2)
FT, right (48) 69.7 (23.6) 89.8 (28.7)
a
FIMFunctional Independence Measure, TMW2-Minute Walk Test, TUGTimed Up & Go Test,
FTFinger Tapping Test.
b
All results were signicantly different between admission and discharge for each outcome measure, as
determined with the Bonferroni correction factor (.007).
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whereas 41% of the subjects who
required physical assistance prior to
admission experienced clinically
meaningful changes.
Discussion
In the present study, we investigated
the effectiveness of a multidisciplinary
movement disorders program in an in-
patient rehabilitation environment for
people with a diagnosis of typical id-
iopathic PD. Most importantly, the re-
sults revealed that people with a diag-
nosis of PD as a primary condition
made signicant improvements in FIM
total, motor, and cognitive scores and
in TMW, TUG, and FT scores follow-
ing admission to an inpatient rehabili-
tation hospital. The gains of 71% of
these people exceeded the MCID for
the FIM total score.
Despite a growing body of literature
demonstrating the benets of exer-
cise and rehabilitation for patients
with PD, it is not part of standard
practice in the United States to refer
patients with PD for rehabilitation
services. Historically, inpatient reha-
bilitation admission has not been
considered for patients with a
chronic, progressive disease such as
PD unless there has been an acute
event, such as a fracture or pneumo-
nia. Despite the inclusion of PD as 1
of the 13 designated medical condi-
tions for which intensive inpatient
rehabilitation services have been de-
termined to be medically necessary
by the Centers for Medicare and
Medicaid Services, patients experi-
encing declines in function related
to their PD typically are not admitted
to inpatient rehabilitation facilities.
The results of the present study dem-
onstrated the benets of inpatient re-
habilitation for people who had pri-
mary, typical idiopathic PD and who
were admitted as a result of frequent
falling, a decline in functional status,
or difculty managing their current
environment. As a result of this de-
cline, they were at risk of losing their
independence and requiring addi-
tional care at home or in an institu-
tionalized setting. Despite the
chronic, progressive nature of PD,
most people made statistically sig-
nicant and clinically meaningful
gains from admission to discharge.
This nding suggested the benets
of systematic pharmacological ad-
justments combined with intensive
rehabilitation and 24-hour monitor-
ing over a mean length of stay of 21
days. The outcomes of the present
study, in which the participants pre-
dominantly had PD of Hoehn and
Yahr stages III and IV, are consistent
with the results of rehabilitation
studies conducted on an outpatient
basis in which the participants typi-
cally had PD of Hoehn and Yahr
stages II and III, suggesting the ben-
ets of rehabilitation in later stages
of the disease.
2,4
The improvements observed in the
FIM motor, TMW, and TUG scores
demonstrated changes at the func-
tional level. Although people with
PD are thought to have decits in
motor learning, they appear to be
able to learn new, more effective
strategies to help improve walking,
rising from a chair, moving in bed,
and performing ADL tasks. Daily
practice of tasks in the present study
allowed multiple repetitions for peo-
ple to learn successful solutions.
Smiley-Oyen and colleagues
28
found
that patients with PD were able to
learn and retain 2 different move-
ment sequences following extensive
practice, with the majority of the
changes occurring at between 1 and
2 weeks. In addition, a recent study
29
suggested that patients with PD may
benet more from blocked practice
than from random practice of tasks.
This nding suggested that many
Figure.
Functional Independence Measure (FIM) total change scores above and below the
minimal clinically important difference of 22.
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repetitions of the same task, which
occurred during the inpatient reha-
bilitation admission in the present
study, may have been an important
component of the intervention. In ad-
dition, research suggests that patients
with PDare capable of activating com-
pensatory cortical mechanisms to fa-
cilitate the execution of motor tasks
in the presence of a dopamine decit
in the frontostriatal motor circuits.
30
The external cueing strategies imple-
mented in the present study to im-
prove gait function may have served to
enhance the recruitment of cortical ar-
eas while bypassing the poorly func-
tioning basal ganglia.
31
Studies
22,24,32
also support the benets of stretch-
ing, strengthening, and endurance
training for people with PD. Although
these components were included in
the intervention in the present study,
changes in these areas were not ex-
plicitly measured. Therefore, their
contributions to the improvements
made in function are unknown.
We considered whether the gains
made in the present study were
clinically signicant in addition to
being statistically signicant. The
change score of 22 was associ-
ated with an MCID in people after
stroke.
27
However, because this
cutoff score was derived from peo-
ple who had had a stroke, it may
not be the most appropriate cutoff
score for determining clinically
meaningful change in people with
PD. The data from the stroke study
served as a starting point from
which to interpret the clinical rel-
evance of our ndings, given the
lack of research on determining
MCIDs in outcome measures used
for people with PD following phar-
macological or rehabilitation inter-
ventions. Given that the gains of
71% of the subjects with PD ex-
ceeded the MCID of 22, it is plau-
sible that the results for a substan-
tial proportion of our sample of
subjects would have continued to
exceed the threshold even if the
cutoff score were higher.
The ability to identify people with
PD most likely to benet from inpa-
tient rehabilitation would help phy-
sicians and rehabilitation teams tar-
get patients more appropriately. The
value of identifying important deter-
minants of rehabilitation outcome
has been demonstrated for other do-
mains, such as stroke
33
and chronic
obstructive lung disease,
34
but has
not been investigated for PD. In the
present study, prior level of function
accounted for 20% of the variance
in the FIM total change score. This
result suggests the value of baseline
status in predicting rehabilitation out-
come. Additional studies with larger
samples are needed to further investi-
gate the predictors of rehabilitation
outcome.
There are several limitations of the
present study. The lack of a con-
trol group limited our ability to at-
tribute the improvements observed
specically to rehabilitation or to
the combination of pharmacologi-
cal and rehabilitation interventions.
Improvements attributable to other
aspects of an inpatient hospital ad-
mission also cannot be ruled out.
However, given the natural history
of the disease, people with PD would
not be expected to show improve-
ments without intervention, particu-
larly given the magnitude of the gains
revealed in our results. In a recent
randomized controlled trial investi-
gating the efcacy of a rehabilitation
program in an outpatient setting,
we found that 38 subjects in a no-
treatment control condition (medica-
tion management only) showed a
mean improvement of only 0.9 m (3
ft) in TMW scores over a 6-week pe-
riod (unpublished data). In contrast,
there was a mean gain of 24 m (80 ft)
over a mean of 20 days in the present
study.
Another limitation of the present
study was the lack of follow-up after
discharge. Although the gains made
were substantial, it is unknown
whether the subjects were able to
transfer these gains to their home
environments. Even if the subjects
were able to translate the gains made
in the rehabilitation hospital to their
home environments, it is unknown
how long these gains were main-
tained. In addition, improvements in
the present study were measured at
the functional level. Changes in QOL
and neurological impairments were
not measured and should be consid-
ered in future studies. Measuring
changes in the brain may also be
important because studies investigat-
ing the impact of exercise in animal
models of parkinsonism have sug-
gested that forced exercise of the
affected limb may reduce the vulner-
ability of dopamine neurons, in part
because of an increase in the avail-
ability of glial cell line-derived neu-
rotrophic factor.
35,36
Further re-
search is needed to investigate the
potential neuroprotective effects of
exercise on the progression of PD in
humans during various stages of the
disease process.
Conclusion
The results of the present study sug-
gested that subjects with a primary
diagnosis of idiopathic PD beneted
from a multidisciplinary movement
disorders program in an inpatient re-
habilitation setting. Subjects with a
primary diagnosis of PD (N68)
showed signicant improvements in
FIM total, motor, and cognitive
scores as well as in TMW, TUG, and
left and right FT scores over a mean
length of stay of 21 days. Improve-
ments exceeded the MCID for the
FIM total score in 71% of subjects
with PD. Prior level of function at
admission accounted for 20% of the
variance in the FIM total change
score, suggesting the value of base-
line status in predicting outcome.
Inpatient Multidisciplinary Rehabilitation for Parkinson Disease
818 f Physical Therapy Volume 88 Number 7 July 2008
by guest on February 3, 2014 http://ptjournal.apta.org/ Downloaded from
All authors provided concept/idea/research
design and consultation (including review of
manuscript before submission). Dr Ellis and
Dr Katz provided writing and project man-
agement. Dr Ellis, Dr Katz, and Dr White
provided data analysis. Dr Ellis, Dr Katz, and
Dr Saint-Hilaire provided institutional liai-
sons. The authors sincerely thank all of those
whose dedication and commitment to the
development and implementation of the
Movement Disorders Program at Braintree
Rehabilitation Hospital were invaluable:
Valerie Allen, Nancy Broderick, Cristen Clark,
Christina Collin, Katrina Grifth, Kelley
Kuzak, Alissa Leonard, Kelly McIntyre, Daniel
Parkinson, Tamara Rork, Susan Sabadini,
Kristin Sternowski, and Cathi Thomas.
This study was approved by the Boston Uni-
versity Institutional Review Board and the
Braintree Rehabilitation Hospital Medical Ex-
ecutive Committee.
This study was supported by the Dudley
Allen Sargent Research Fund.
This study was presented, in part, as a poster
at the American Congress of Rehabilitation
MedicineAmerican Society of Neuroreha-
bilitation conference; September 28
October 2, 2005; Chicago, Ill.
This article was received September 11, 2007,
and was accepted February 26, 2008.
DOI: 10.2522/ptj.20070265
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Inpatient Multidisciplinary Rehabilitation for Parkinson Disease
July 2008 Volume 88 Number 7 Physical Therapy f 819
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doi: 10.2522/ptj.20070265
Originally published online April 24, 2008
2008; 88:812-819. PHYS THER.
DePiero, Anna D Hohler and Marie Saint-Hilaire
Terry Ellis, Douglas I Katz, Daniel K White, T Joy
Disease
Rehabilitation Program for People With Parkinson
Effectiveness of an Inpatient Multidisciplinary
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