Download The Benefits of Group Occupational Therapy for Patients With

The Benefits of Group
Occupational Therapy
for Patients With
Parkinson's Disease
Louise Gauthier, Sandra Dalziel,
Serge Gauthier
Key Words: group processes. Parkinson's
disease, therapy. services, occupational
therapy
The medical treatment of idiopathic Parkinson's
disease has improved the quality of life and increased survival ofpatients with Parkinson's disease. However, as the illness progresses, impairments in daily living activities occur. A clinical
trial for a group rehabilitation program was initiated to maintain the functional status of these
patients.
The research protocol consisted of a pretreatment evaluation, random assignment to experimental or control groups, and posttreatment evaluations after therapy, at 6 months and at 1 year.
The results showed that the subjects of the
treated experimental group maintained their functional status after 1 year, demonstrated a signifi·
cant decrease of bradykinesia, and perceived a significant improvement in their psychological
well-being.
This study confirms the value of an occupational therapy group approach and its benefits to
the functional independence, to the improvement of
physical and motor symptoms, and to the quality of
life ofpersons with Parkinson's disease.
Louise Gauthier, OT( C), MSc, is Assistant Professor,
School of Physical anc! Occupational Therapy, McGill
University, 3654 Drummond, Montreal, Quebec, Canada
H3G lY5
Sandra Dalziel, OT(C), is a research assistant, School of
Physical and Occupational Therapy, McGill University.
Serge Gauthier, MD, FRCP(C), is Associate Professor. Department of Neurology and Neurosurgery and Department
of Psychiatry, McGill University.
360
T
he current medical treatment of anticholinergic
drugs and dopamine agonists has improved the
quality of life of patients and increased the life
expectancy of patients with idiopathic Parkinson's
disease (IPD) (Hoehn, 1983). In the pre-L-dopa era,
the mortality rate was three times that of the general
population (Hoehn & Yahr, 1967), and it decreased
to one-and-a-half times the general rate after the introduction of L-dopa (Yahr, 1976)_ The duration of
the illness is now extended to beyond 10 years, on
the average, and it is estimated that the prevalence of
the disease will double in forthcoming years (Marttila
& Rinne, 1979) Problems have emerged from the Ldopa treatment itself (Marsden & Parkes, 1977; Lesser
et aI., 1979), because the medical introduction of Ldopa or other dopamine agonists, as well as the ideal
dosage, are still matters of controversy_ Some of the
parkinsonian symptoms, such as akinesia and rigidity,
have been responsive to the medication. On the other
hand, postural instability and tremor at rest have been
rather resistant to the medical treatment.
Previously we had studied, by formal interview,
the relationship between physical symptoms and activities of daily living (ADL) in patients with Parkinson's disease. Our work showed that tremor at rest
had negligible effects on ADL, but that postural instability was the major element in disability at home and
at work, leading to premature retirement in many
young patients (Gauthier & Gauthier, 1982, 1983).
The impairments in functional activities intensified
with the severity of the disease; in the early stages,
difficulties with activities requiring trunk mobility and
postural reflexes were encountered. Later on, manipulation and dexterity problems appeared, creating
dependence for eating, dressing, washing, and so on.
The rehabilitation of patients with Parkinson's disease
seems indicated to promote a better quality of life, to
increase productiVity in society, and to improve the
overall prognosis. Rehabilitation group programs with
specific goals have been suggested (Davis, 1977;
Szekely, Kosanovich, & Sheppard, 1982; Minnigh,
1971; Chafetz, Bernstein, Sharpe, & Schwab, 1955).
The aim of the present study was to establish
whether a group rehabilitation program using an occupational therapy approach specifically designed for
IPD patients, in association with optimal pharmacologic management, could maintain the functional status of these patients. If so, the work would suggest
(a) that outpatient rehabilitation is a useful adjunct to
current medical therapy and (b) that functional rehabilitation is required to decrease the debilitating
effects of this degenerative, neurological disease.
To test this hypothesis, a two-group experimental
design was used. Patients with Parkinson's disease,
after having signed an informed consent form, were
randomly assigned to either a control group or to an
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experimental group receiving group occupational
therapy. In this single-blind study, both groups were
evaluated pre- and postintervention, at 6 months and
at 1 year.
Methods
Subjects
The target population was patients with IPD. To be
included, patients must have (a) had IPD for at least
1 year; (b) had parkinsonism staging of 2,3, or 4 (ie.,
ambulatory with bilateral involvement) (Hoehn &
Yahr, 1967); (c) been living at home; (d) been able
to attend follow-up assessments; (e) and been willing
to sign an informed consent form. To facilitate attendance at the group therapy sessions, all volunteers
had to reside within the city limits or surrounding
suburbs.
Design
Sixteen volunteers with IPD were evaluated neurologically and functionally. After this pretesting, the
volunteers were randomly assigned to a "rehabilita
tion" group (n = 8) or a "control" group (n = 8).
Immediately after randomization, the rehabilitation
grou p received 10 sessions of group occu pational
therapy. Both groups were followed medically, and
both were reevaluated after the therapy sessions, at 6
months and then at 1 year posttreatment A total of 4
such matched groups were cumulated over 2 years.
The size of the rehabilitation group was kept small to
promote efficacious group therapy and motivation of
the patients with Parkinson's disease.
Instruments
All testing took place at the Montreal eurological
Institute and Hospital before noon. Evaluators were
blind to the results of randomization. The Barthel
Index (Mahoney & Barth I, 1965) was used to evaluate the functional autonomy in ADL. The Purdue
Pegboard Test (Tiffin, 1968) assessed the dexterity of
fingers, hands, and arms The Extrapyramidal Symptom Rating Scale (Chouinard, Ross-Chouinard, Annable, & Jones, 1980) quantified the physical and motor
signs. To determine whether the group therapy sessions had an impact on the emotional health of the
patients, the rehabilitation group was given the Bradburn Index of Psychological Well-Being (Bradburn,
1969) before and after therapy.
members were welcome and often participated in all
actiVities.
For each experimental group there were 10 sessions, on a schedule of 2 meetings a week for 5 weeks.
Each session was held in the morning and lasted
approximately 2 hours. The content of each session
followed the pattern of (a) arrival (welcome and
socialization), (b) general mobility activities, (c) rest
period and socialization, (d) dexterity activities, (e)
functional activities, (f) educational activities, and (g)
departure (informal exchange and socialization).
During each session, four main components were
touched upon: general mobility, dexterity, ADL, and
education. Activities and tasks were chosen to address
specific problems of patients with Parkinson's disease According to Marsden (1984), patients with
Parkinson's disease maintain simple motor programs,
but the automatic execution of learned motor plans
is disturbed. Therefore, these patients exhibit delay
in the initiation of movement, slowness in the execution, and inability to "engage into" sequential motor actions.
To facilitate initiation and speed of movement,
most activities employed visual and auditory cues as
triggers. Visual cues were looking at and follOWing
the therapist'S or another group member's movements. A mirror was also used. Auditory cues were
music with regular rhythm, a metronome, verbal suggestions, and reinforcement from the therapiSt.
The general mobility activities addressed the follOWing problems; balance, posture, walking, range of
motion, and facial mobility. These activities used
rhythm, music, singing, and dancing to initiate movement and to increase postural stability. The dexterity
tasks aimed at better finger manipulation, accuracy,
and speed by the use of games, writing exercises, and
crafts. During the functional activities period, we discussed, demonstrated, and practiced all indoor and
outdoor activities of daily living presenting difficulties for the group. Finally, the educational activities
which sought to prOVide a better understanding of
Parkinson's disease were presented by the two therapists or by invited guests (e.g., a physical therapist,
speech pathologist, dietician, social worker, nurse).
Each patient had a therapy book with lists of activities
to do at home, summaries of guests' lectures, and
literature on Parkinson's disease.
Results
Group Therapy Sessions
Population
All therapy sessions were conducted at the School of
Physical and Occupational Therapy, McGill Univer
sity, by the principal investigator as group leader, and
an occupational therapist as a professional assistant.
An audiovisual assistant was also present in order to
videotape the 5th and 10th group sessions. Family
Of the 64 original volunteers, only 5 did not complete
the study Three members of the experimental group
dropped out One refused the therapy because she
felt too weak to attend 5 weeks of sessions; one was
hospitalized for gastrointestinal surgery during the
therapy period; and one fell and broke a hip just
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361
before starting the group sessions Two control subjects did not complete all the follow-up assessments
One was stranded in Lebanon, and one withdrew for
personal reasons just after randomization. Data indicate that the preevaluation scores of these 5 subjects
were comparable to those of the other subjects; it is
therefore unlikely that the benefits of randomization
were lost.
At the end of the study, a total of 59 patients with
Parkinson's disease had been able to complete the 1year follow-up: The experimental rehabilitation group
had 30 patients, and the control group, 29 At preevaluation, there was no significant difference between the two groups for staging of IPD, sex, duration
of disease, and pharmacological treatment (chisquare). The mean age for the experimental group
was 60.9 ± 6.9 years, and for the control group, 65.3
± 75 years. The distribution for parkinsonism staging
(Hoehn & Yahr, 1967) describing the severity of the
disease was equivalent for each group (see Table 1).
Functional Autonomy
The Barthel Index scores of the pretreatment evaluation were compared with the scores obtained at 1
year. The Wilcoxon Matched- Pairs Signed Ranks Tests
(2-tailed) showed us that the treated rehabilitation
group maintained their functional status over 1 year.
However, the control group demonstrated a significant deterioration in their autonomy (see Table 2)
Dexterity
As for finger manipulation and dexterity, unilateral
and bilateral scores on the Purdue Pegboard Test did
not show any changes in either group from pretreatment assessment to 6-month and I-year follow-up
evaluations.
Patients'lmpressions
We also inquired about the subjects' perceptions of
their disease. The Bradburn Index of psychological
well-being, which was administered to the treated
group just before and after therapy, showed that the
patients perceived greater psychological well-being
after the therapy (p < .03, t test). Moreover, the first
part of the Extrapyramidal Symptoms Rating Scale,
whereby a neurologist records the patient's impression of his or her symptoms and rates the responses,
showed that the experimental group perceived a
Table 1
Distribution of Parkinsonism Staging
Experimental
Stages
2
3
4
362
Table 2
Barthel Index Scores
Group
Pretest
1 Year
Experimental (n = 30)
Comro! (n = 29)
927 ± 94
926 ± 109
90 ± 1Z'
947 ± 7
• Wilcoxon Matched·Pairs Signed Ranks Test (Z-lailed), p <03.
regression of the severity of their symptoms at 6
months posttreatment; there were no changes in the
control group (p < .03, t test).
Physical and flilotor Signs
As preViously mentioned, the Extrapyramidal Symptoms Rating Scale was used to quantify physical and
motor signs. In the control group, there were no
significant changes for any physical signs at the posttreatment evaluations at 6 months and at 1 year. The
treated rehabilitation group demonstrated numerous
changes at the posttreatment evaluations, including a
significant diminution of bradykinesia and akathisia
at 6 months, and of bradykinesia at 1 year. Table 3
summarizes the physical and motor signs in which
changes were discerned
The stage of parkinsonism denotes the degree to
which the patient is affected by the disease. There
were no significant changes in the staging of the
control group at any time. However, 10 patients in
the rehabilitation group showed a significant decrease
in their staging ranking at 6 months (p < .01, Sign
Test)
Behavioral Changes
A number of unassessed or unassessable changes
were also observed in the rehabilitation group. First,
there was a marked amelioration of physical appearance (grooming, choice of clothes, etc). Appraising
remarks of group members confirmed the therapists'
observations.
The treated patients also demonstrated a clear
understanding of Parkinson's disease. This knowledge has helped to decrease their fear and to increase
their self-assurance. From the 1st to the 10th session,
we noted significant changes in attitudes, from egocentricity at the beginning to interested and concerned involvement with others at the end. The group
situation furnished for all patients an opportunity for
greater socialization and communication. Also, an
important factor was the presence of family members
because they too learned about IPD and witnessed
the residual potential of their affected relative.
Summary o/Results
Group (n = 30)
Control Group
(n = 29)
11
14
lZ
14
5
3
In summary, after 20 hours of group occupational
therapy as Zln adjunct to medical therapy, patients with
Parkinson's disease maintained their functional status
over 1 year, whereas the control patients exhibited a
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Table 3
Physical and Motor Signs
Posttrearment
Groups
(En = 30;
en = 29)
Sign
Expressive automatic movements
2. Bradykinesia
3
Gait and posture
4. Tremor
E
12
10
18
e
9
E
18
e
9
E
16
11
15
e
E
5 Akathisia
Note E = experimental group;
E
e
e
e=
9
6 Months
+
p<'
2
5
4
8
6
6
5
4
4
5
OJ
3
004
1
02
6
02
64
.01
42
12
8
18
12
15
14
10
11
14
10
1 Year
+
p<*
4
6
5
8
6
5
12
11
07
79
01
5
07
06
83
3
7
1
01
62
+
14
6
19
9
11
10
14
12
16
11
5
5
4
8
8
8
6
6
6
6
p<*
06
1
003
1
64
81
11
66
23
.33
conrrol group .• Sign test.
decrease of their independence with progression of
this degenerative disease. The rehabilitation group
itself perceived this progression as being less severe
than that of the control group.
At 6 months, there was a diminution of bradykinesia and akathisia in the rehabilitation group. Even
at 1 year, bradykinesia had regressed in the treated
group, and we believe that this long-term benefit is
the result of education and the home exercise pro
gram. At 6 months, the treated group showed a decrease in severity of IPD staging. Finally, a number of
changes, both observed by the therapists and reported
by the treated patients, have led to a better quality of
life, socialization, and family interaction.
Discussion
Patients with Parkinson's disease are infrequently
hospitalized and seldom referred to rehabilitation
professionals. Generally, they are referred to physical
therapy when their gait becomes unstable However,
Beattie and Caird (1980) and Gauthier and Gauthier
(1982) have detected the presence of numerous functional problems. A review of the rehabilitation literature reveals that motor symptoms (rigidity, akinesia,
tremor) receive the most attention from researchers.
On the basis of practical experience, techniques from
Bobath to Rood are proposed for patients with Parkinson's disease. Few controlled clinical trials have been
reported. Gibberd, Page, Spencer, Kinnear, and
Hawksworth (1981) conducted a controlled crossover
trial of physiotherapy and occupational therapy. Unfortunately, their trial had many flaws: The treatment
methods (Bobath, Peto, PNF) varied with patients;
the control group received "inactive" treatment that
could affect the outcome; and the number of patients
was small (N = 16) The authors concluded that
remedial therapy for outpatients with Parkinson's disease was valueless Considering the methodology of
this trial, we believe the results are unacceptable and
prejudicial to the welfare of the patients with Parkinson's disease Another study by Franklyn, Kohout,
Stern, and Dunning (1981) tried to evaluate the effi-
cacy of physiotherapeutic techniques; this trial
showed modest improvement at the end of treatment
in 10 of 21 patients. However, the authors themselves
feel their study was inconclusive since the benefits
were not sustained and they could not identify the
reasons for these improvements, They expressed the
need for other trials. In 1982, Szekely et al (1982)
conducted a pilot project of physical therapy and
group therapy which included the family to improve
functioning of patients with Parkinson's disease. This
study, however, included only 7 volunteers and no
control group. Nevertheless, the results showed a
significant improvement in gait measures, and the
group approach seemed to have enhanced motivation
The present study seemed necessary to demonstrate the value of functional rehabilitation for this
population. Based on previous reports (Davis, 1977;
Szekely et a!., 1982; Minnigh, 1971), we chose a grou p
approach to facilitate the participation and the motivation of the patients with Parkinson's disease because this group is distinguished by its social isolation, sedentary habits (Manson & Caird, 1985), and
depression (Todes, 1984; Serby, 1980).
The group approach achieved more behavioral
changes than an indiVidual, more dependent, clienttherapist relationship would have achieved. This experience has shown that the group therapy is well
suited for patients with chronic degenerative diseases
who are easily drawn into depression and social isolation. The group proVides a supportive environment
and facilitates interactions among peers. The group
approach is also very cost-effective; only one or two
therapists are needed for 8 to 10 patients for a period
of 20 hours. This therapy format is almost a necessity,
since the number of patients with Parkinson's disease
will likely double in the near future.
Certainly, any type of experimental study involving patients with a degenerative, neurological disease
and sometimes fluctuating symptoms has its limitations. However, our study was conducted with scientific rigor such that inferences can be made. All subjects were volunteers who had been tested before
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363
their random assignment to the groups, Both experimental and control groups were equivalent for the
crucial variables of sex, severity of the disease, duration of the disease, and pharmacological treatment,
Results from any subject who underwent an uncontrolled event (such as another illness) between measurements were not considered in the results_ Only
results from patients who completed all the evaluations, including the I-year evaluation, were taken into
account in the analysis,
The learning effects on tests and the Hawthorne!
placebo effect (special attention) were minimized or
nonexistent since tbe significant end result is
achieved at 1 year, None of the measurements were
used during the therapy sessions, The blind evaluators
had no contact with or feedback from the intervention
processes, All testing sessions were done between 9
and 12 o'clock in the morning to decrease variations
in performance due to the time of day. We have
enough confidence in the experimental design to
generalize the data and affirm that functional rehabilitation through occupational therapy is of benefit to
the outpatients with Parkinson's disease, Previously,
it was a matter of controversy whether patients would
be better assessed and treated at home or in hospital
outpatient departments (Beattie & Caird, 1980; Gibberd et a!., 1981), We suggest that referral to rehabilitation therapy should be considered every 6 months
to maintain the functional status and autonomy of the
patients as long as possible, After the completion of
our study, 13 control subjects asked to enter the group
rehabilitation program, Because project results indicated that the program did indeed benefit the patients
with Parkinson's disease, we complied with their requests for ethical reasons,
The main goals of the group therapy sessions
have been described: general mobility, dexterity,
ADL, and education, The treatment goals and the
activities for each of these goals can be varied according to the population and to the environment, but it
is important to keep in mind that interventions addressing motor and functional problems should be
coupled with interventions aimed at improving socialization, motivation, interpersonal and family relationships, self-esteem, and knowledge of the disease,
Summary
The results of this experimental study of patients with
Parkinson's disease demonstrate the benefits of occupational therapy for chronically ill, noninstitutionalized patients, In this particular case, a group therapy
program aimed at the biopsychosocial aspects of the
disease maintained the functional status of the patients in the experimental group, improved their psychological well-being, decreased the severity of one
364
of the major motor symptoms (bradykinesia), and
facilitated several positive behavioral changes,
Acknowledgments
We thank the many patients with Parkinson's disease for
participating in this study, The assistance of Jane Boucher
(testing of patients), Johanne Thibault (videotaping), and
Fran~ois Dehaut (data analysis) is also greatly appreciated,
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