doi: 10.2522/ptj.20070265Originally published online April 24, 2008

2008; 88:812-819.PHYS THER. DePiero, Anna D Hohler and Marie Saint-HilaireTerry Ellis, Douglas I Katz, Daniel K White, T JoyDiseaseRehabilitation Program for People With Parkinson Effectiveness of an Inpatient Multidisciplinary

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Effectiveness of an InpatientMultidisciplinary RehabilitationProgram for People WithParkinson DiseaseTerry 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 difficult toeffectively manage the complex medical and rehabilitation needs of people withParkinson disease (PD). A multidisciplinary approach in the inpatient rehabilitationenvironment may be a viable alternative. The purposes of this study were: (1) toinvestigate the effectiveness of an inpatient rehabilitation program for people with aprimary diagnosis of PD, (2) to determine whether gains made were clinicallymeaningful, and (3) to identify predictors of rehabilitation outcome.

Subjects. Sixty-eight subjects with a diagnosis of PD were admitted to an inpatientrehabilitation 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 of3 hours per day, 5 to 7 days per week, in addition to pharmacological adjustmentsbased on data collected daily. A pretest-posttest design was implemented. Thedifferences between admission and discharge scores on the Functional IndependenceMeasure (FIM) (total, motor, and cognitive scores), Timed “Up & Go” Test, 2-MinuteWalk Test, and Finger Tapping Test were analyzed.

Results. An analysis of data obtained for the 68 subjects admitted with a diagnosisof PD revealed significant improvements across all outcome measures from admissionto discharge. Subjects with PD whose medications were not adjusted during theiradmission (rehabilitation only) (n�10) showed significant 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 accountedfor 20% of the variance in the FIM total change score.

Discussion and Conclusion. The results suggest that subjects with a diagnosisof PD as a primary condition benefited from an inpatient rehabilitation programdesigned to improve functional status.

T Ellis, PT, PhD, NCS, is ClinicalAssociate Professor, Departmentof Physical Therapy and AthleticTraining, Sargent College ofHealth 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 Therapistand 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, Schoolof Medicine, Boston University, andDirector, Brain Injury Program, De-partment of Neurology, BraintreeRehabilitation Hospital.

DK White, PT, ScD, NCS, is Post-doctoral Research Fellow, ClinicalEpidemiology Research TrainingUnit, School of Medicine, BostonUniversity.

TJ DePiero, MD, is Assistant Profes-sor, Department of Neurology,School of Medicine, Boston Uni-versity, and Medical Director,Stroke Program, Department ofNeurology, 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, BraintreeRehabilitation Hospital.

M Saint-Hilaire, MD, FRCPC, is As-sistant Professor, Department ofNeurology, 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 programfor people with Parkinson disease.Phys Ther. 2008;88:812–819.]

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Parkinson disease (PD) is a pro-gressive neurological disordercharacterized by insidious on-

set. Despite pharmacological andsurgical interventions, people face arelentless deterioration in mobilityand activities of daily living (ADL).The clinical hallmarks of the diseaseinclude rigidity, bradykinesia, tremor,and loss of postural control. Theseimpairments lead to a decline infunctional status, so that people withPD have difficulty performing taskssuch as walking, rising from a chair,and moving in bed. This decrease infunctional status often results in aloss of independence and a declinein quality of life (QOL).

Although a Cochrane review1 of ran-domized controlled trials (RCTs) re-ported that there is insufficient evi-dence to support or refute theefficacy of physical therapy in PD, anumber of intervention studies havefound positive effects of physicaltherapy in addition to medicationtherapy (MT) in people with PD ofHoehn and Yahr stage II or III. Ameta-analysis of 12 studies (RCTs andquasi-experimental designs) investi-gating the effects of physical therapyin addition to MT in people with PDdemonstrated significant summaryeffect sizes with regard to ADL (0.40),stride length (0.46), and walkingspeed (0.49).2 A meta-analysis of 16studies investigating the effects ofoccupational therapy for people withPD revealed significant summary ef-fect sizes for outcomes classified atthe capabilities and abilities level(0.5) and the activities and taskslevel (0.54).3 A large-scale RCT (con-ducted after the Cochrane review)investigating the efficacy of physicaltherapy plus MT interventions inpeople with PD revealed significantdifferences between groups in theareas of comfortable walking speed,ADL, and QOL related to physical mo-bility.4 Effect sizes in this RCT wereconsistent with those reported in the2 meta-analyses described above.

The impact of rehabilitation may begreater if implemented in an in-patient setting. In the outpatient en-vironment, it becomes increasinglychallenging to make optimal changesin medication regimens with a briefvisit to the neurologist. Patients’symptoms become more complex(dyskinesia, freezing, motor fluctua-tions, hallucinations, and loss of pos-tural control) and difficult to manageas the disease progresses. Observationtime is limited, and neurologists mustrely on patients’ reports for informa-tion on the type, timing, and durationof symptoms. The inpatient environ-ment, however, may be a viable alter-native in which selected patients witha primary diagnosis of PD can receiveeffective management when they ex-perience more complex symptoms, adecline in function, or frequent falls orare in jeopardy of losing their indepen-dence. With admission to an inpatientmultidisciplinary rehabilitation hospi-tal, patients can participate in dailytherapies in an environment that al-lows continuous monitoring of func-tional status and medication responseby a team that is knowledgeable aboutmovement disorders. Although pa-tients with PD often are admitted to aninpatient rehabilitation program fol-lowing an orthopedic, cardiopulmo-nary, or general medical procedure(secondary diagnosis of PD), patientswith PD as the primary diagnosis arenot typically referred for inpatientrehabilitation.

The purposes of this study were todetermine whether people with a di-agnosis of idiopathic PD as a primarycondition showed improvements infunctional status following partici-pation in a specialized inpatientmultidisciplinary rehabilitation pro-gram and to determine whether theimprovements observed exceededthe minimal clinically important dif-ference (MCID). In addition, the sub-group of people who did not havemedication adjustments during theiradmission was analyzed separately

to examine changes attributable torehabilitation only. This study alsoidentified the determinants that bestpredicted rehabilitation outcome.We hypothesized that people withPD would show statistically and clin-ically significant increases in func-tional abilities following participa-tion in an inpatient multidisciplinaryrehabilitation program administeredby a rehabilitation team with exper-tise in movement disorders. We alsohypothesized that disease durationand baseline functional status wouldbe important predictors of rehabili-tation outcome.

MethodDesign and SubjectsA pretest-posttest design was used toevaluate the effectiveness of a move-ment disorders program for subjectswho were admitted to an inpatientrehabilitation hospital with a diagno-sis of idiopathic PD. Subjects wereadmitted to inpatient rehabilitationfrom an acute care hospital, home, askilled nursing facility, or an assistedliving facility from January 2004 toDecember 2006; were diagnosedwith typical idiopathic PD by a neu-rologist specializing in movementdisorders, according to the UnitedKingdom Parkinson’s Disease Soci-ety Brain Bank’s clinical diagnosticcriteria5; were at least 18 years ofage; and were classified as having PDof Hoehn and Yahr stages I to V. Atotal of 68 subjects who met thesecriteria were admitted to the move-ment disorders program. Baselinecharacteristics of the subjects areshown in Table 1.

Outcome MeasuresThe primary outcome measure usedto address the study aims was theFunctional Independence Measure(FIM) total score.6,7 Secondary out-come measures were the FIM motorscore, the FIM cognitive score, the2-Minute Walk Test (TMW),8 theTimed “Up & Go” Test (TUG),9 andthe Finger Tapping Test (FT).10

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The FIM is a widely used measure offunctional status developed specifi-cally for people in inpatient acutecare rehabilitation facilities. The FIMcomprises 2 sections: motor (13items) and cognitive (5 items). Theseitems are rated with regard to theperformance of ADL tasks on a7-point ordinal scale from a score of1 (complete dependence) to a scoreof 7 (independence), with a maxi-mum possible total score of 126. TheFIM has well-established reliabilityand validity as a generic instru-ment.6,7 It also has been shown to beresponsive to change following in-tervention in people who have had astroke11 but has not been studied inpeople 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 distanceas possible on foot in 2 minutes, be-ing told, “Keep walking until I tellyou to stop.” A tester accompaniedthe subject, acting as a timekeeperand guarding as needed. Light and

colleagues8 demonstrated that sub-jects with PD walk a significantlyshorter distance (X��88 m [294 ft])than sex- and age-matched controlsubjects (X��182 m [608 ft]).

The TUG is a quick test incorporat-ing a transfer from a sitting positionto a standing position, ambulation,and turning, which are frequentlyimpaired in people with movementdisorders.9 Interrater reliability hasbeen demonstrated to be excellent(intraclass correlation coefficient�.99) using the TUG in people withPD.12 The subjects were seated in achair with arms on the armrests andwere instructed to stand, walkto a point 3 m (10 ft) away, turnaround, walk back to the chair, andsit. One practice trial and one testtrial were recorded. The subjectswere allowed to use an assistive de-vice if necessary. Normative valuesfor older people range from 10 to 11seconds without a cane and from11.5 to 15.2 seconds with a cane.13

The FT was used to measure theimpact of common symptoms ofmovement disorders (bradykinesia,dyskinesia, and tremor) on upper-extremity function. This measurewas used to determine the impact ofmedication adjustments and rehabil-itation on the upper extremities, par-ticularly in subjects who werenonambulatory and unable to partic-ipate in other assessments. The FThas been shown to be reliable andvalid.10,14 Two buttons attached tocounters were mounted 30 cm apart.The subjects alternated tapping ofthe buttons with the left hand for 1minute. The sum of the taps on bothbuttons was the result for the lefthand. The test then was repeatedwith the right hand.

InterventionThe program used in this study was acomprehensive, specialized, inpa-tient multidisciplinary rehabilitationprogram. The aim of this programwas to optimize the subjects’ medi-cation regimens and functional abili-ties through a team approach. Themovement disorders team consistedof a consulting neurologist with spe-cialization in movement disorders,attending neurologists (at the inpa-tient rehabilitation facility) with spe-cialization in neurorehabilitation, amovement disorders fellow, physicaltherapists, occupational therapists,speech-language pathologists, nurses,and case managers. Specific assess-ment and treatment approaches weredeveloped for this movement disor-ders program, and staff received reg-ular in-service education on themanagement of PD and movementdisorders.

In addition to the outcome measuresadministered at admission and dis-charge, daily measures (TMW, TUG,and FT) were obtained at both thepeak and the trough times of themedication cycle in order to capturefluctuations in a subject’s 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. (%) (n�58)

I 0 (0)

II 1 (2)

III 18 (31)

IV 37 (64)

V 2 (3)

Level of function prior to admission, no. (%) (n�58)

Physical assistance required 22 (38)

No physical assistance required 36 (62)

Discharge disposition, no. (%) discharged to home (n�67) 47 (70)

Length of stay, d, X (SD) 20.8 (7.8)

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tered both the intervention and theoutcome measures, all therapy staffinvolved in data collection partici-pated in multiple training sessions inorder 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. Onthe basis of this information, deci-sions regarding appropriate medica-tion changes were made. An addi-tional weekly movement disordersteam meeting was held to discusssubjects’ responses to the medica-tion adjustments and to examine ad-ditional data points. Further changeswere made as needed, and this pro-cess was continued until the subjectswere discharged.

Throughout their length of stay, sub-jects participated in a combinationof physical therapy, occupationaltherapy, and speech therapy for aminimum of 3 hours per day, 5 to 7

days per week. Therapy was pro-vided on an individual basis and in agroup format when appropriate. Thecomponents of the interventionwere based on “best evidence” fromthe literature.15 These componentsincluded the use of external cueingto improve gait speed, step length,and cadence16–18; the application ofcognitive movement strategies to im-prove bed mobility and transfers19,20;balance training21; exercises to im-prove joint mobility22,23 and strength(force-generating capacity)24; andvoice treatment to improve volumeand 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 studyparticipant.

Data AnalysisMeans, standard deviations, and fre-quency distributions were calculatedto describe subjects’ baseline char-acteristics, length of stay, and dis-

charge disposition. The effectivenessof the specialized inpatient multi-disciplinary rehabilitation programwas evaluated by comparing admis-sion and discharge mean scores oneach of the outcome measures de-scribed above. Parametric statisticswere applied because the data for alloutcome measures were normallydistributed. Two-tailed paired t testswere conducted with the alpha levelset 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 participatedin rehabilitation in addition to hav-ing medication adjustments and forsubjects who participated in rehabil-itation but whose PD medicationswere not changed (rehabilitationonly) during their inpatient admis-sion. In addition, the clinical signifi-cance of the improvements observedwas determined on the basis of theFIM total change scores. An FIM totalchange score of �22 has been

Table 2.Description of the Intervention

Category Description

Functional traininga 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 oruntil subject reaches maximum capacity

Reducing freezing (context specific: doorways, thresholds, and narrow spaces) with visual cues inthe form of lines on the floor from tape or laser beams

Turning strategies (wide-arc)

Improving adaptation (various walking surfaces, obstacles in the environment, starting andstopping, and turning head while walking)

Curb negotiation and stair climbing

Range-of-motion, flexibility, andstrengthening exercises

Range of motion (increase trunk extension and rotation)

Stretching (hip flexor, 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-specific practice conducted in a blocked fashion; complex movements were simplified intosubcomponents 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 theMCID in people who have had astroke.27 Therefore, in our study, achange from baseline to discharge of�22 was considered clinically mean-ingful, whereas a change of less than22 was considered too small to beclinically meaningful.

To determine the relationship be-tween baseline indices (independentvariables) and treatment outcomes(dependent variables), we conducteda univariate analysis with Pearsoncorrelation coefficients. The followingfactors served as predictor (inde-pendent) variables: age, disease dura-tion, sex, education level, Hoehn andYahr stage, prior level of function(physical assistance required or not re-quired for daily bed mobility, transferfrom 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 statuson each of the outcome measures. Thedependent variable was FIM totalchange score (discharge status minusadmission status). A stepwise regres-sion analysis was conducted to iden-tify which determinants identified assignificant (P�.20) in the univariateanalysis predicted rehabilitation out-

come. The significance of each vari-able entered into the regression analy-sis was determined with a t test, thesignificance of R2 was determinedwith an F test, and the level of signifi-cance was set at .05. Colinearity diag-nostics were applied for each variableentered into the regression analysis inorder to control for unstable estimatesof entered regression coefficients. Alldata analyses were performed withSPSS Professional Statistics (version15.0) software (for Windows).*

ResultsAll SubjectsAn analysis performed on the entiresample of subjects (N�68) revealedstatistically significant improvementsacross all outcome measures fromadmission to discharge (Tab. 3). TheFIM total score improved by a meanof 31.5 (95% confidence interval[CI]�28.0–35.1). The analysis alsorevealed mean improvements of27.7 (95% CI�24.6–30.7) on the mo-tor section of the FIM, 4.1 (95%CI�3.0–5.1) on the cognitive sec-tion of the FIM, 21.0 m (69 ft)(95% CI�14.7–27.3) on the TMW,19.8 seconds (95% CI�8.7–30.8)on the TUG, 19.2 finger taps (95%CI�13.4–25.0) on the left, and 20.1

finger taps (95% CI�13.6–26.7) onthe right. The mean length of staywas 20.8 days, with 47 (70%) of thesubjects being discharged to home.

Subjects WithoutMedication AdjustmentsFor 10 of the 68 subjects who hadPD and who were admitted for reha-bilitation, PD medications were notadjusted. These subjects receivedrehabilitation only. There were sta-tistically significant improvements(P�.007) in FIM total score, witha mean increase of 32.0 (95%CI�23.4–40.6), in FIM motor score,with a mean increase of 27.0 (95%CI�20.1–33.9), and in FIM cognitivescore, with a mean increase of 5.0(95% CI�2.2–7.8). The TUG scoresincreased by a mean of 61.6 seconds(95% CI�14.3–108.8), a finding thatapproached statistical significance(P�.017). The TMW and FT scoresdid not reach statistical significance.

Predictors ofRehabilitation OutcomeSignificant correlations were foundbetween the FIM total change scoreand prior level of function and be-tween the FIM total change scoreand the presence of dyskinesia onadmission. A lower prior level offunction and the presence of dyski-nesia were associated with less im-provement in the FIM total score.Prior level of function accounted for20% of the variance in the FIM totalchange score (Tab. 3). The presenceof dyskinesia did not significantly im-prove model fit.

MCID in the FIM Total ScoreAll subjects made gains in the FIMtotal score, with a range of improve-ments from 4 to 75. Forty-eight sub-jects (71%) showed changes of �22in the total FIM score, representingclinically important differences (Fig-ure). Eighty-three percent of the sub-jects who did not require physicalassistance prior to admission experi-enced clinically meaningful changes,

* SPSS Inc, 233 S Wacker Dr, Chicago, IL60606.

Table 3.Admission and Discharge Scores

Measurea

(No. of Subjects)X (SD) Scoreb 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 FIM�Functional Independence Measure, TMW�2-Minute Walk Test, TUG�Timed “Up & Go” Test,FT�Finger Tapping Test.b All results were significantly different between admission and discharge for each outcome measure, asdetermined with the Bonferroni correction factor (��.007).

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whereas 41% of the subjects whorequired physical assistance prior toadmission experienced clinicallymeaningful changes.

DiscussionIn the present study, we investigatedthe effectiveness of a multidisciplinarymovement disorders program in an in-patient rehabilitation environment forpeople 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 conditionmade significant improvements in FIMtotal, motor, and cognitive scores andin TMW, TUG, and FT scores follow-ing admission to an inpatient rehabili-tation hospital. The gains of 71% ofthese people exceeded the MCID forthe FIM total score.

Despite a growing body of literaturedemonstrating the benefits of exer-cise and rehabilitation for patientswith PD, it is not part of standardpractice in the United States to referpatients with PD for rehabilitationservices. Historically, inpatient reha-bilitation admission has not beenconsidered for patients with achronic, progressive disease such asPD unless there has been an acuteevent, such as a fracture or pneumo-nia. Despite the inclusion of PD as 1of the 13 designated medical condi-tions for which intensive inpatientrehabilitation services have been de-termined to be medically necessaryby the Centers for Medicare andMedicaid Services, patients experi-encing declines in function relatedto their PD typically are not admittedto inpatient rehabilitation facilities.

The results of the present study dem-onstrated the benefits of inpatient re-habilitation for people who had pri-mary, typical idiopathic PD and whowere admitted as a result of frequentfalling, a decline in functional status,or difficulty managing their currentenvironment. 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 thechronic, progressive nature of PD,most people made statistically sig-nificant and clinically meaningfulgains from admission to discharge.This finding suggested the benefitsof systematic pharmacological ad-justments combined with intensiverehabilitation and 24-hour monitor-ing over a mean length of stay of 21days. The outcomes of the presentstudy, in which the participants pre-dominantly had PD of Hoehn andYahr stages III and IV, are consistentwith the results of rehabilitationstudies conducted on an outpatientbasis in which the participants typi-cally had PD of Hoehn and Yahrstages II and III, suggesting the ben-efits of rehabilitation in later stagesof the disease.2,4

The improvements observed in theFIM motor, TMW, and TUG scoresdemonstrated changes at the func-tional level. Although people withPD are thought to have deficits inmotor learning, they appear to beable to learn new, more effectivestrategies to help improve walking,rising from a chair, moving in bed,and performing ADL tasks. Dailypractice of tasks in the present studyallowed multiple repetitions for peo-ple to learn successful solutions.Smiley-Oyen and colleagues28 foundthat patients with PD were able tolearn and retain 2 different move-ment sequences following extensivepractice, with the majority of thechanges occurring at between 1 and2 weeks. In addition, a recent study29

suggested that patients with PD maybenefit more from blocked practicethan from random practice of tasks.This finding suggested that many

Figure.Functional Independence Measure (FIM) total change scores above and below theminimal clinically important difference of 22.

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repetitions of the same task, whichoccurred during the inpatient reha-bilitation admission in the presentstudy, may have been an importantcomponent of the intervention. In ad-dition, research suggests that patientswith PD are capable of activating com-pensatory cortical mechanisms to fa-cilitate the execution of motor tasksin the presence of a dopamine deficitin the frontostriatal motor circuits.30

The external cueing strategies imple-mented in the present study to im-prove gait function may have served toenhance the recruitment of cortical ar-eas while bypassing the poorly func-tioning basal ganglia.31 Studies22,24,32

also support the benefits of stretch-ing, strengthening, and endurancetraining for people with PD. Althoughthese components were included inthe intervention in the present study,changes in these areas were not ex-plicitly measured. Therefore, theircontributions to the improvementsmade in function are unknown.

We considered whether the gainsmade in the present study wereclinically significant in addition tobeing statistically significant. Thechange score of �22 was associ-ated with an MCID in people afterstroke.27 However, because thiscutoff score was derived from peo-ple who had had a stroke, it maynot be the most appropriate cutoffscore for determining clinicallymeaningful change in people withPD. The data from the stroke studyserved as a starting point fromwhich to interpret the clinical rel-evance of our findings, given thelack of research on determiningMCIDs in outcome measures usedfor people with PD following phar-macological or rehabilitation inter-ventions. Given that the gains of71% 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 ofsubjects would have continued to

exceed the threshold even if thecutoff score were higher.

The ability to identify people withPD most likely to benefit from inpa-tient rehabilitation would help phy-sicians and rehabilitation teams tar-get patients more appropriately. Thevalue of identifying important deter-minants of rehabilitation outcomehas been demonstrated for other do-mains, such as stroke33 and chronicobstructive lung disease,34 but hasnot been investigated for PD. In thepresent study, prior level of functionaccounted for 20% of the variancein the FIM total change score. Thisresult suggests the value of baselinestatus in predicting rehabilitation out-come. Additional studies with largersamples are needed to further investi-gate the predictors of rehabilitationoutcome.

There are several limitations of thepresent study. The lack of a con-trol group limited our ability to at-tribute the improvements observedspecifically to rehabilitation or tothe combination of pharmacologi-cal and rehabilitation interventions.Improvements attributable to otheraspects of an inpatient hospital ad-mission also cannot be ruled out.However, given the natural historyof the disease, people with PD wouldnot be expected to show improve-ments without intervention, particu-larly given the magnitude of the gainsrevealed in our results. In a recentrandomized controlled trial investi-gating the efficacy of a rehabilitationprogram in an outpatient setting,we found that 38 subjects in a no-treatment control condition (medica-tion management only) showed amean improvement of only 0.9 m (3ft) 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 presentstudy.

Another limitation of the presentstudy was the lack of follow-up afterdischarge. Although the gains madewere substantial, it is unknownwhether the subjects were able totransfer these gains to their homeenvironments. Even if the subjectswere able to translate the gains madein the rehabilitation hospital to theirhome environments, it is unknownhow long these gains were main-tained. In addition, improvements inthe present study were measured atthe functional level. Changes in QOLand neurological impairments werenot measured and should be consid-ered in future studies. Measuringchanges in the brain may also beimportant because studies investigat-ing the impact of exercise in animalmodels of parkinsonism have sug-gested that forced exercise of theaffected limb may reduce the vulner-ability of dopamine neurons, in partbecause of an increase in the avail-ability of glial cell line-derived neu-rotrophic factor.35,36 Further re-search is needed to investigate thepotential neuroprotective effects ofexercise on the progression of PD inhumans during various stages of thedisease process.

ConclusionThe results of the present study sug-gested that subjects with a primarydiagnosis of idiopathic PD benefitedfrom a multidisciplinary movementdisorders program in an inpatient re-habilitation setting. Subjects with aprimary diagnosis of PD (N�68)showed significant improvements inFIM total, motor, and cognitivescores as well as in TMW, TUG, andleft and right FT scores over a meanlength of stay of 21 days. Improve-ments exceeded the MCID for theFIM total score in 71% of subjectswith PD. Prior level of function atadmission accounted for 20% of thevariance in the FIM total changescore, suggesting the value of base-line status in predicting outcome.

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All authors provided concept/idea/researchdesign and consultation (including review ofmanuscript before submission). Dr Ellis andDr Katz provided writing and project man-agement. Dr Ellis, Dr Katz, and Dr Whiteprovided data analysis. Dr Ellis, Dr Katz, andDr Saint-Hilaire provided institutional liai-sons. The authors sincerely thank all of thosewhose dedication and commitment to thedevelopment and implementation of theMovement Disorders Program at BraintreeRehabilitation Hospital were invaluable:Valerie Allen, Nancy Broderick, Cristen Clark,Christina Collin, Katrina Griffith, KelleyKuzak, Alissa Leonard, Kelly McIntyre, DanielParkinson, Tamara Rork, Susan Sabadini,Kristin Sternowski, and Cathi Thomas.

This study was approved by the Boston Uni-versity Institutional Review Board and theBraintree Rehabilitation Hospital Medical Ex-ecutive Committee.

This study was supported by the DudleyAllen Sargent Research Fund.

This study was presented, in part, as a posterat the American Congress of RehabilitationMedicine–American 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 by guest on February 3, 2014http://ptjournal.apta.org/Downloaded from

doi: 10.2522/ptj.20070265Originally published online April 24, 2008

2008; 88:812-819.PHYS THER. DePiero, Anna D Hohler and Marie Saint-HilaireTerry Ellis, Douglas I Katz, Daniel K White, T JoyDiseaseRehabilitation Program for People With Parkinson Effectiveness of an Inpatient Multidisciplinary

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