Occupational Therapy Practice Guidelines for People With Parkinson’s Disease

Abstract

Importance: Occupational therapy practitioners address the occupational performance and participation needs of people with Parkinson’s disease (PD) and their care partners.

Objective: This Practice Guideline is informed by systematic reviews on the use of occupational therapy interventions to promote participation in occupations for people with PD and to facilitate their caregivers’ participation in the caregiver role. This guideline is meant to support practitioners’ clinical decision making when working with people with PD and their care partners.

Method: We examined and synthesized the results of four systematic reviews and integrated those results into clinical recommendations for practice.

Results: Thirty-three articles from the systematic reviews served as the basis for the clinical recommendations in this Practice Guideline. Clinical recommendations are provided for interventions that have strong or moderate supporting evidence.

Conclusion and Recommendations: Multidisciplinary, tailored, goal-oriented intervention is recommended for people with PD. Various forms of exercise can be used to improve activities of daily living and instrumental activities of daily living performance and social participation, and interventions should incorporate health behavior change techniques to support adequate physical activity levels in daily life. Mindfulness meditation and exercise can be used to support sleep, and task-oriented training can be used to improve performance of specific tasks. Occupational therapy practitioners should incorporate self-management, coaching, compensatory, cognitive–behavioral, and other approaches into multicomponent treatment plans depending on the client’s needs and goals. Additional potentially appropriate intervention approaches or areas to address are discussed on the basis of existing or emerging evidence and expert opinion.

What This Article Adds: This Practice Guideline provides a summary and applications of the current evidence supporting occupational therapy intervention for people with PD. It includes case examples and suggested decision-making algorithms to support practitioners in addressing client goals.

This Practice Guideline provides a summary and applications of current evidence supporting a multidisciplinary, tailored, and goal-oriented intervention that is recommended for people with Parkinson’s disease. Case examples are presented along with suggested decision-making algorithms to support practitioners in addressing client goals.

Parkinson’s disease (PD) is a chronic, progressive neurodegenerative condition associated with progressive synucleinopathy, degeneration of nigrostriatal dopaminergic neurons, basal ganglia dysfunction, and widespread functional brain network disruptions. As a result of these neuropathological changes, people with PD experience myriad insidious motor and nonmotor signs and symptoms that can negatively affect their occupational performance, participation, and quality of life (QOL). Although the cause of PD remains largely unknown and there is no cure, treatment options are available to manage this complex and heterogeneous condition.

Approximately 1 million people in North America currently live with PD (Marras et al., 2018). This number is rising steeply as the population ages and life expectancy increases, making PD the fastest growing neurological disorder in the world (GBD 2016 Parkinson’s Disease Collaborators, 2018). Men are about 1.5 times more likely than women to be diagnosed with PD, and a majority of studies have reported the highest prevalence in White populations (Ben-Joseph et al., 2020; Wright Willis et al., 2010). The incidence of PD increases with age; the current average age at diagnosis is around age 60 yr. Thus, many people with PD have almost two full decades after diagnosis to fully live and experience life.

Each person with PD possesses a unique combination of signs and symptoms that can affect their well-being and ability to safely and independently engage in their desired occupations. PD is traditionally characterized by a complex set of motor signs including bradykinesia, akinesia, rigidity, tremor, and postural instability, which result in a decline in initiation, speed, and coordination of fine and gross motor function; impaired mobility; and speech and swallowing dysfunction. Despite the classification of PD as a movement disorder, a wide array of nonmotor manifestations are also associated with it, such as cognitive impairment, fatigue, neuropsychiatric concerns (e.g., depression, anxiety), sleep disturbances, sensory dysfunction (e.g., pain, loss of olfaction, visual problems), and autonomic disruptions. These nonmotor issues may appear earlier and have a greater impact on function and QOL than the motor signs (Martinez-Martin et al., 2011; Müller et al., 2013; Poewe, 2008).

People with PD have available a variety of treatment options for managing the multidimensional nature of their disease. One common approach is the use of a tailored and closely monitored medication regimen to control symptoms. Initially, people with PD experience a good response to medication. As the disease progresses, however, they may notice unpredictable changes in function because the medication wears off before they take the next dose (sometimes called on–off syndrome), and medications may become less effective over time. In addition, antiparkinsonian medications typically do not relieve the nonmotor symptoms and may even make them worse, and the long-standing use of such medications is frequently associated with negative side effects (e.g., dyskinesias, impulse control disorder, hallucinations). Surgery, such as deep brain stimulation or lesioning, is an option for people whose symptoms are not controlled effectively by medication or who are experiencing troublesome medication side effects. Regardless of the course of the disease and the combination of treatment, people with PD and their care partners need a multidisciplinary, client- and family-centered approach to best address their unique needs (Qamar et al., 2017; Radder et al., 2017; van der Marck et al., 2009).

“Achieving health, well-being, and participation in life through engagement in occupation” summarizes the domain and process of occupational therapy in its fullest sense (American Occupational Therapy Association [AOTA], 2020, p. 5). The role of occupational therapy practitioners in the care of people with PD is to promote their engagement in meaningful tasks, activities, and roles in the home and community (Foster et al., 2014; Jansa & Aragon, 2015; Radder et al., 2017). Limitations in daily activities among people with PD can occur soon after diagnosis and typically progress over the course of the disease (Schenkman et al., 2011). Occupational performance problems can stem from any number or combination of factors, including motor and nonmotor impairments, medication regimens, and environmental barriers. The varied and unique presentation of PD across individuals requires practitioners to combine a client-centered approach to assessment and intervention with models of practice (e.g., Model of Human Occupation, Person–Environment–Occupation–Performance Model) and theoretical models (e.g., motor learning, challenge point framework) to address this complex condition (Jansa & Aragon, 2015).

Treatment goals may differ over the progression of the disease within and across individuals. For example, in the early stages of PD, occupational therapy intervention may be directed toward self-management, prevention of reduced participation in roles and activities, and enhancement of activity performance. In the middle and later stages of PD, occupational therapy intervention may shift focus toward adaptation and compensation to preserve engagement and independence in meaningful activities. Over the course of the disease, practitioners continually assess the environment, other contextual factors, and task demands and modify them as necessary to support the client’s optimal safety, independence, comfort, and satisfaction in daily occupational performance. In addition, they play a role in supporting care partners to appropriately assist the person with PD in daily activities while remaining mindful of their own needs to maintain well-being (Radder et al., 2017).

Although people with PD and their care partners desire nonmedical interventions, and although growing evidence supports the role of occupational therapy in the management of PD, occupational therapy services are underutilized by this population in the United States. A claims-based study identified 174,643 Medicare beneficiaries with a diagnosis of PD and followed them from 2007 to 2009, tracking annual receipt of physical, occupational, and speech therapy services (Fullard et al., 2017). In 2007, only 14.2% of beneficiaries with PD had claims for physical or occupational therapy, and this rate showed a small decline from 2007 to 2009. In contrast, rehabilitation utilization rates among people with PD in the Netherlands and the United Kingdom were more than 50% around that time period (Fullard et al., 2017; Jansa et al., 2011; Keus et al., 2004). Furthermore, a survey of the experiences and views of people with PD in four European countries found that of those who had received occupational therapy services since their diagnosis, almost all would recommend occupational therapy to other people with PD (Jansa et al., 2011). Clear, evidence-based, and practical guidelines may help fill the gap between the perceived value and actual utilization of occupational therapy by people with PD in the United States.

The current Practice Guideline updates the PD portion of the Occupational Therapy Practice Guidelines for Adults With Neurodegenerative Diseases (Preissner, 2014). Those guidelines, which were based on a systematic review of occupational therapy–related interventions for adults with PD (Foster et al., 2014), discussed three categories of interventions: (1) exercise or physical activity; (2) environmental cues, stimuli, and objects; and (3) self-management and cognitive– behavioral strategies. The clinical recommendations for PD included supporting clients’ engagement in exercise and physical activity to improve their performance skills and occupational performance, specifically through (1) multisession repetitive physical exercise to improve balance, postural stability, and motor performance and (2) complex and multimodal activity (e.g., tango dancing) to improve functional movement. Other review findings indicated that specialized or more intense exercise can improve performance to a greater extent than traditional or less-intense exercise, task-specific interventions can improve skill development, tai chi can enhance motor and postural performance skills, and multimodal physical activity can improve cognitive performance. The previous guidelines also recommended the use of external cues during movement and activities of daily living (ADLs) to improve task and occupational performance, with auditory rhythmic external cues being most effective for walking. Finally, the guidelines recommended individualized interventions focused on wellness and personal control through self-management and cognitive–behavioral strategies to improve QOL.

At the time of the prior Practice Guideline (Preissner, 2014), research focused on interventions and outcomes for people with PD at the physical activity and impairment level, on one hand, and related occupation-based interventions and outcomes, on the other, was just beginning to emerge. The literature has since evolved, and the set of systematic reviews that informed the current Practice Guidelines updated and expanded on the prior evidence. Three of the systematic reviews examined outcomes of interest in three occupational domains: ADLs, rest, and sleep (Doucet et al., 2021); instrumental activities of daily living (IADLs; Foster et al., 2021); and education, work, volunteering, leisure, and social participation (Reiling Ott & Kolodziejczak, 2020), and one focused on interventions for caregivers of people with PD (Boone et al., 2021). Thus, this Practice Guideline incorporates enhanced and additional evidence to support occupational therapy practice with adults with PD. The information in this Practice Guideline reflects the current state of the research for interventions within the scope of occupational therapy for people with PD and their caregivers and can be used to support evidence-based practice.

Systematic Review Questions

This Practice Guideline is based on the following four questions:

What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve or maintain performance and participation in ADLs and rest and sleep for adults with PD (Doucet et al., 2021)?

What is the evidence for the effectiveness of interventions within the scope of occupational therapy to improve or maintain performance and participation in IADLs for adults with PD (Foster et al., 2021)?

What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve or maintain the performance of and participation in education, work, volunteering, leisure, and social participation among adults with PD (Reiling Ott & Kolodziejczak, 2020)?

What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people with PD to facilitate or maintain their participation in the caregiver role (Boone et al., 2021)?

Goals of This Practice Guideline

Through this Practice Guideline, AOTA aims to help occupational therapy practitioners, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, understand occupational therapy’s contribution in providing services to people with PD and their care partners. This guideline can also serve as a reference for health care professionals, health care facility managers, education professionals, education and health care regulators, third-party payers, managed care organizations, and those who conduct research to advance care of people with PD.

This Practice Guideline was commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. It was financially supported entirely by AOTA and was developed without any involvement of industry. All authors of the reviews completed conflict-of-interest disclosure forms, with no conflicts noted. AOTA reviews practice guidelines, and updates them as needed, every 5 years to keep recommendations on each topic current according to criteria established by ECRI (2021). Guideline topics are evaluated by a multidisciplinary advisory group consisting of AOTA members, nonmember content experts, and external stakeholders. This Practice Guideline was reviewed and revised on the basis of feedback from a group of content experts on people with PD that included practitioners, researchers, educators, practitioners, and policy experts. Reviewers who agreed to be identified are listed in the Acknowledgments.

This Practice Guideline reports the findings from systematic reviews of published scientific research on focused topic-specific questions. The systematic reviews were conducted according to the Cochrane Collaboration methodology (Higgins et al., 2019) and are reported according to the PRISMA guidelines for conducting systematic reviews (Moher et al., 2009). The protocol and questions were developed with input from a multidisciplinary advisory group that also included consumers and information end users. A medical research librarian conducted searches of the literature, and review teams evaluated the search results and synthesized the findings (see the Appendix for an overview of the systematic review methods and findings). Interventions that were described in sources other than the published literature and that did not meet the inclusion criteria were excluded from the reviews.

Occupational therapy practitioners should not consider this Practice Guideline to be a source of comprehensive information about PD or about application of the occupational therapy process. The occupational therapist makes the ultimate clinical judgment regarding the appropriateness of a given intervention in light of a specific client’s or group’s circumstances, needs, and response to intervention, as well as the evidence available to support the intervention. Examples of how evidence can inform practice with people with PD are included in the “Clinical Case Studies and Algorithms” section.

AOTA supported the systematic reviews on the effectiveness of interventions within the scope of occupational therapy for people with PD as part of its Evidence-Based Practice (EBP) Project. AOTA’s EBP Project is based on the principle that the evidence-based practice of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research. The systematic reviews and this Practice Guideline report the findings from the best available research.

Clinical Recommendations for Occupational Therapy Interventions for People With Parkinson’s Disease

Clinical recommendations are the final phase of the synthesis of systematic review findings. The findings for each systematic review question are graded in terms of how confident a practitioner can feel that using the interventions presented in the evidence will improve the outcomes of interest to their clients. The grade is based on the specificity of the intervention, number of studies supporting the intervention, levels of evidence of the studies, quality of the studies, and significance of the study findings. Interventions included in the clinical recommendations are specific to a population, and the articles that describe them provide sufficient detail for practitioners to understand the intervention and the outcomes of interest.

Describing the strength of clinical recommendations is an important part of communicating an intervention’s efficacy to practitioners and other users. The recommendations for this practice guideline were evaluated and finalized by AOTA staff, the AOTA research methodologist, and systematic review and practice guideline authors. AOTA uses the grading methodology provided by the U.S. Preventive Services Task Force (2018) for clinical recommendations. The clinical recommendations pertaining to each review, along with the studies’ level of evidence and supporting details, are presented in Tables 1–3. No strong or moderate clinical recommendations emerged from the systematic review on caregiver interventions, so there is no corresponding table.

Table 1.

Clinical Recommendations and Supporting Evidence: Interventions to Address ADLs, Sleep, and Rest for People With PD

Grade/Evidence Level	Citation	Intervention Details
A: Strong	Recommendation: Practitioners should consider using multidisciplinary inpatient rehabilitation (4–8 wk) to improve ADL performance.
Level 1b	Ferrazzoli et al. (2018)	Participants: N = 250 (M age = 67 yr; 57% male) Setting: Inpatient rehabilitation hospital (Italy) Intervention: Rehab (1 hr each of PT, treadmill gait, ST, and OT), 4 hr/day 5 days/wk and 1 hr exercise on 6th day over 4 wk. OT sessions included hand and finger exercises, ADL training, and self-management and cognitive–behavioral strategies. Outcome measures: PDQ–39, UPDRS, PPDS, TUG, BBS
Level 1b	Frazzitta, Maestri, Ferrazzoli, et al. (2015)	Participants: N = 138 (M age = 69 yr; 44% male) Setting: Inpatient rehabilitation (Italy) Intervention: MIRT (1 hr each of cardiovascular and stretching warm-up, PT exercises to improve balance and gait, and OT), 3 hr/day 5 days/wk for 4 wk. OT sessions consisted of transfer, bed mobility, and dressing training; exercises to improve hand function and skills; and home exercise program. Outcome measures: PDSS Italian version; UPDRS II, III, and Total scores
Level 1b	Monticone et al. (2015)	Participants: N = 70 (M age = 75 yr; 66% female; M disease duration = 15 yr) Setting: Rehabilitation center (Italy) Intervention: Multidisciplinary inpatient rehabilitation, 3 hr/day 7 days/wk for 8 wk. OT sessions consisted of adaptive strategy training and equipment assessment and training with a focus on ADL performance. Outcome measures: UPDRS III, BBS, FIM^®, PDQ–39
Level 2b	Frazzitta, Maestri, Bertotti, et al. (2015)	Participants: N = 40 (M age = 72 yr; 53% male) Setting: Inpatient rehabilitation (Italy) Intervention: MIRT (1 hr each of cardiovascular and stretching warm-up, PT exercises to improve balance and gait, and OT), 3 hr/day 5 days/wk for 4 wk. OT sessions consisted of transfer, bed mobility, and dressing training; exercises to improve hand function and skills; and home exercise program. Outcome measures: UPDRS II and III, TUG, 6-min walk test, PDDS
Level 2b	Frazzitta et al. (2014)	Participants: N = 30 (M age = 72 yr; 37% male; M disease duration = 6 yr) Setting: Inpatient rehabilitation (Italy) Intervention: Inpatient rehabilitation treatment with multimodal activity, 1 hr/day 5 days/wk for 4 wk. OT sessions consisted of transfer, bed mobility, and dressing training; adaptive equipment training; and hand exercises and tasks. Outcome measures: Serum BDNF concentration, UPDRS II and III, BBS, 6-min walk test
Level 2b	Frazzitta et al. (2012)	Participants: N = 50 (M age = 71 yr; 48% male) Setting: Inpatient rehabilitation (Italy) Intervention: IRT (1 hr each of cardiovascular and stretching warm-up, PT exercises to improve balance and gait, and OT), 3 hr/day 5 days/wk for 4 wk. OT sessions consisted of transfer, bed mobility, and dressing training; exercises to improve hand function and skills; and home exercise program. Outcome measures: UPDRS II, III, and Total scores
B: Moderate	Recommendation: Practitioners could consider using a group multimodal exercise program (2–5×/wk) incorporating flexibility, balance, Wii games, and function-based exercises to improve ADL performance.
Level 1b	Schenkman et al. (2011)	Participants: N = 121 (M age NR; 37% female) Setting: Outpatient clinic (United States) Intervention: Functional balance group program (flexibility, functional balance, and functional exercise), 1 hr/day 3×/wk for 4 mo. Outcome measures: CS–PFP, FRT, UPDRS II and III, PDQ–39
Level 1b	Wallén et al. (2018)	Participants: N = 100 (M age = 73 yr; 43% female) Setting: Inpatient rehabilitation (Sweden) Intervention: Group balance and gait exercises and dual-task (cognitive and motor) training, 60 min 3×/wk for 10 wk. Four balance components specific to balance impairments in PD were emphasized: sensory integration, anticipatory postural adjustments, motor agility, and stability limits. Outcome measures: Mini BEST, gait velocity, UPDRS II
Level 2b	Pedreira et al. (2013)	Participants: N = 44 (M age = 63 yr; 71% male) Setting: Outpatient clinic (Brazil) Intervention: Individually conducted Wii exercises, 40 min 3 days/wk for 4 wk. Nintendo Wii is a home videogame with several exercises that allow training on strength, balance, and aerobics. Players are motivated to defeat their adversaries in specific trainings such as boxing, and they can track their progress over time, enhancing adherence and concentration in their physical activity. Outcome measures: UPDRS, PDQ–39
Level 2b	Pompeu et al. (2012)	Participants: N = 32 (M age = 68 yr; 53% male; H&Y stage 1 and 2) Setting: Community (Brazil) Intervention: Individual training consisting of 30 min of stretching, resistance strengthening, and axial mobility exercises plus 30 min of traditional balance training (control group) or Wii Fit games with cognitive component (intervention group), 1 hr/day 2 days/wk for 7 wk. Outcome measures: UPDRS II
Level 2b	Volpe et al. (2014)	Participants: N = 34 (M age = 67 yr; gender NR; M H&Y stage = 2.82) Setting: Outpatient clinic (Italy) Intervention: Water-based cardiovascular program with warm-up, stretching, and balance training, 60 min 5 days/wk for 2 mo. Outcome measures: UPDRS II and III, TUG, BBS, ABC Scale, FES, falls diary, PDQ–39
B: Moderate	Recommendation: Practitioners could consider using a home-based hand exercise program (e.g., HOMEDEXT; crossing circles, turning discs, nuts on bolts, and manipulating modeling clay and wooden balls) (30 min/day 5 days/wk for 4 wk) to improve ADL performance.
Level 1b	Vanbellingen et al. (2017)	Participants: N = 103 (M age = 68 yr; 65% male; M H&Y stage = 1.94) Setting: Home (Switzerland) Intervention: HOMEDEXT, a home-based manual dexterity program, 30 min/day 5 days/wk for 4 wk. Outcome measures: 9HPT, PDQ–39 Items 11–16, DextQ–24, self-reported ADL and IADL performance, coin rotation task, hand strength (Jamar dynamometer), MDS–UPDRS II Items 2.4–2.7, MDS–UPDRS III
B: Moderate	Recommendation: Practitioners could consider using resistance training and multimodal exercise (2–3×/wk for 3–6 mo) to improve sleep quality and reduce sleep disturbances.
Level 2b	Nascimento et al. (2014)	Participants: N = 34 (M age = 67 yr; 50% male; M H&Y stage = 1.6) Setting: Community (Brazil) Intervention: Multimodal exercise program with exercise at 60%–80% of maximum HR consisting of warm-up; resistance exercises; balance and coordination tasks, especially recreational and rhythmic; and aerobic circuit, 1 hr 3×/wk for 6 mo. Outcome measures: MSQ Brazilian version
Level 2b	Silva-Batista et al. (2017)	Participants: N = 22 (M age = 64 yr; 74% male; M H&Y stage = 2.5) Setting: University laboratory gym (Brazil) Intervention: Resistance training on both stable and unstable surfaces, 50 min 2×/wk for 12 wk. Outcome measures: UPDRS III, PSQI
B: Moderate	Recommendation: Practitioners could consider using a community-based mindfulness meditation and exercise program (6 sessions over 8 wk) to improve sleep disturbances.
Level 1b	Son & Choi (2018)	Participants: N = 63 (M age 65 yr; 63% female; H&Y Stages 1–3) Setting: Community (Korea) Intervention: MMBCEP combining MBSR with the Senior Fitness Test Manual, 2 hr 1×/wk over 8 wk for a total of 6 sessions. Outcome measures: PDSS, Barthel Index, PDQL
B: Moderate	Recommendation: Practitioners could consider using a community-based mindfulness program (1×/wk for 6–8 wk) to improve ADL performance.
Level 1b	Son & Choi (2018)	Participants: N = 63, 63% female; H&Y Stages 1–3) Setting: Community (Korea) Intervention: 8-wk MMBCEP combining MBSR with the Senior Fitness Test Manual; 2 hr 1×/wk for 8 wk for a total of 6 sessions. Outcome measures: PDSS, Barthel Index, PDQL
Level 2b	Advocat et al. (2016)	Participants: N = 72 (M age = 63.3 yr; 58% female; M H&Y stage = 2). Setting: Community (Australia) Intervention: Facilitated mindfulness-based group program to introduce key lifestyle and mindfulness elements, 2 hr 1×/wk over 8 wk for a total of 6 sessions. Outcome measures: PDQ–39 (subcategories analyzed separately), Freiburg Mindfulness Inventory, DASS–21
B: Moderate	Recommendation: Practitioners could consider using virtual training interventions on a Wii, Xbox, or Kinect system (2–3×/wk for 5–7 wk) to improve ADL performance.
Level 2b	Özgönenel et al. (2016)	Participants: N = 33 (M age = 65 yr; 66% male) Setting: Inpatient rehabilitation (Turkey) Intervention: Usual care of hotpack, e-stim to trunk extensors, and multimodal exercise (both groups), plus 3 standing and balance Xbox games (experimental group), 60 min/day 3×/wk for 5 wk. Outcome measures: UPDRS II
Level 3b	da Silva Souza et al. (2018)	Participants: N = 11 (M age = 65 yr; 64% male) Setting: Community (Brazil) Intervention: Kinect virtual reality training, 1 hr 2×/wk for 7 wk. The participants randomly played 4 games of Kinect Adventures! and completed 5 attempts for each game, all of which were performed at the same level of difficulty. The games were selected on the basis of their motor and cognitive demands and included the following: 20,000 Leaks, Space Pop, Reflex Ridge, and River Rush. Outcome measures: PDQ–39 (sections analyzed separately)
Level 3b	Herz et al. (2013)	Participants: N = 20 (M age = 66.7 yr; 65% male) Setting: University laboratory (United States) Intervention: Wii exercises (e.g., aerobics, balance) 40 min 2×/wk for 14 sessions. Outcome measures: UPDRS III, SE-ADL Scale, FIM
B: Moderate	Recommendation: Practitioners could consider using CBT focused on sleep hygiene and behaviors with a combination of home activities and in-person checkups (6–10 wk) to improve sleep.
Level 2b	Patel et al. (2017)	Participants: N = 28 (M age = 64 yr; 57% male) Setting: Home (United States) Intervention: Go! To Sleep, a 1x/day, 6-wk, online CBT program for insomnia that includes daily computer-based feedback tracking participants’ progress and weekly phone reminders regarding participation and self-assessments. Daily program access is encouraged via daily email reminders to complete a sleep log based on the prior night’s sleep pattern. The participant is given individualized feedback on the basis of their sleep log responses as well as a daily sleep efficiency score. Psychoeducation regarding insomnia and strategies to help address their sleep concerns were provided daily. Outcome measures: ESS, PIRS20, ISI, FSS, UPDRS IB and II, PHQ–9
Level 2b	Rios Romenets et al. (2013)	Participants: N = 18 (M age = 66 yr; 90% male) Setting: Outpatient clinic (Canada) Intervention: Sleep hygiene training, CBT, and bright light therapy delivered to 2-person groups, 90 min 1×/wk for 6 wk. Light therapy (light boxes were provided) was administered for 30 min, just before bedtime for participants with predominantly sleep maintenance insomnia and in the morning for participants with sleep onset insomnia and circadian phase delay. Outcome measures: ISI, PSQI, PDSS, sleep diaries, FSS

Note. All studies had statistically significant positive outcomes related to the interventions discussed. ABC Scale = Activities-specific Balance Confidence Scale; ADLs = activities of daily living; BBS = Berg Balance Scale; BDNF = brain-derived neurotrophic factor; CBT = cognitive–behavioral therapy; CS–PFP = Continuous Scale–Physical Functional Performance; DASS–21 = Depression, Anxiety and Stress Scale–21 Items; DextQ–24 = Dexterity Questionnaire 24; ESS = Epworth Sleepiness Scale; FES = Tinetti Falls Efficacy Scale; FRT = Functional Reach Test; FSS = Fatigue Severity Scale; HR = heart rate; H&Y = Hoehn & Yahr Scale; IADLs = instrumental activities of daily living; IRT = intensive rehabilitation treatment; ISI = Insomnia Severity Index; MBSR = mindfulness-based stress reduction; MDS–UPDRS = Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (I = nonmotor ADLs; II = motor ADLs; III = motor skills); Mini-BEST = Mini Balance Evaluation Systems Test; MIRT = multidisciplinary intensive rehabilitation treatment; MMBCEP = mindfulness meditation–based complex exercise program; MSQ = Mini-Sleep Questionnaire; 9HPT = Nine-Hole Peg Test; NR = not reported; OT = occupational therapy; PDDS = Parkinson’s Disease Disability Scale; PDQ–39 = Parkinson’s Disease Questionnaire; PDQL = Parkinson’s Disease Quality of Life Questionnaire; PDSS = Parkinson’s Disease Sleep Scale; PHQ–9 = Patient Health Questionnaire–9; PIRS20 = Pittsburgh Insomnia Rating Scale; PPDS = Parkinson’s Disease Disability Scale; PPT = Physical Performance Test; PSQI = Pittsburgh Sleep Quality Index; PT = physical therapy; SE-ADL Scale = Schwab and England Activities of Daily Living Scale; ST = speech therapy; TUG = Timed Up and Go test; UPDRS = Unified Parkinson’s Disease Rating Scale (II = ADLs; III = motor skills; IB = nonmotor experiences rated by patient with or without caregiver).

Table 2.

Clinical Recommendations and Supporting Evidence: Interventions to Address IADLs for People With PD

Grade/Evidence Level	Citation	Intervention Details
A: Strong	Recommendation: Practitioners should consider using physical activity incorporating education, mentoring, social support and interaction, behavioral change techniques (e.g., goal setting, action planning), and activity monitoring (10 wk–12 mo) to increase physical activity levels (e.g., walking, fitness center, yoga, tango, balance, flexibility).
Level 1b	Goodwin et al. (2011)	Participants: N = 130 (M age = 71 yr; 57% male) Setting: Community (United Kingdom) Intervention: Group strength and balance exercises designed for falls prevention, 60 min 1×/wk for 10 wk, then individually tailored home exercise program to complete 2×/wk. Outcome measures: Phone-FITT
Level 1b	Li et al. (2014)	Participants: N = 195 (M age = 69 yr; 63% male) Setting: Community (United States) Intervention: Group tai chi consisting of 6 movements integrated into an 8-form routine, 60 min 2×/wk for 6 mo. Outcome measures: Self-report of “continuing to exercise” (i.e., exercising ≥30 min ≥2×/wk)
Level 1b	Reuter et al. (2011)	Participants: N = 90 (M age = 62 yr; 50% male) Setting: Community (Germany) Intervention: Nordic walking training consisting of technique and endurance training with encouragement to increase intensity, 70 min 3×/wk for 6 mo. Outcome measures: Activity log last week of the intervention, phone interview (e.g., “Do you continue the training you practiced during the study?” “How often do you exercise per week?”)
Level 1b	van Nimwegen et al. (2013)	Participants: N = 586 (M age = 65 yr; 65% male) Setting: Community (the Netherlands) Intervention: ParkFit, an individually tailored, multifaceted behavioral change program to increase levels of physical activity, consisting of personal activity coaching sessions, an educational brochure about physical activity, goal setting, coping planning, encouragement to participate in group exercise, an ambulatory monitor with feedback about daily physical activity levels, and a personalized website. Maximum of 35 1-hr individual sessions available over 1 yr. Outcome measures: Activity diary, ambulatory activity monitor
Level 2b	Demonceau et al. (2017)	Participants: N = 52 (M age = 65 yr; 65% male) Setting: Community gym (Belgium) Intervention: Supervised exercise consisting of muscle strength training using machines and weights vs. aerobic exercise training on a stationary bike vs. usual care, 60–90 min 2–3×/wk for 12 wk. Outcome measures: PASS
Level 2b	Ridgel et al. (2016)	Participants: N = 30 (M age = 70 yr; 63% male) Setting: Community fitness center (United States) Intervention: Enhanced Exercise Therapy consisting of group psychoeducation, 60 min 1×/wk for 12 wk; peer education and support; and manualized group exercise, 45–60 min 3×/wk for 12 wk. Participants were then given a continuing exercise manual and free access to the fitness facility for the next 12 wk. Outcome measures: IPAQ
B: Moderate	Recommendation: Practitioners could consider using intensive writing amplitude training using colored target zones or writing and drawing exercises with visual and auditory stimuli and calligrams (1–5×/wk for 6–9 wk) to improve letter amplitude, surface area, and superior margin of page.
Level 2b	Nackaerts et al. (2016)	Participants: N = 38 (M age = 63 yr; 61% male) Setting: Home (Belgium) Intervention: Intensive writing amplitude training consisting of pen-and-paper writing and exercises on a touch-sensitive tablet with colored target zones and gradual progression of difficulty and weekly observations, 30 min 5 days/wk for 6 wk. Outcome measures: SOS handwriting amplitude
Level 2b	Ziliotto et al. (2015)	Participants: N = 60 (M age = 66 yr; 45% male) Setting: University laboratory (Argentina) Intervention: Handwriting rehabilitation training consisting of writing exercises using different external visual and auditory stimuli and the execution of calligrams, 90 min 1×/wk for 9 wk. Outcome measures: Assessment of a handwritten phrase (handwriting amplitude, progressive reduction, direction, surface area, superior margin, force exerted, velocity)
B: Moderate	Recommendation: Practitioners could consider using home-based handwriting training (hand exercises and writing activities; 2×/wk for 6 mo) with a monthly support session to improve self-reported handwriting performance.
Level 1b	Collett et al. (2017)	Participants: N = 105 (M age = 67 yr; 63% male) Setting: Home (United Kingdom) Intervention: Handwriting training delivered using a workbook with hand exercises and a variety of writing activities, 1 hr 2×/wk for 6 mo, plus monthly visits to review progress. Outcome measures: MDS–UPDRS Item 2.7 (perceived handwriting difficulty)
B: Moderate	Recommendation: Practitioners could consider providing 1:1 home therapy sessions to assess medications, problem solve nonadherence, reflect on the client’s experience with medication, and discuss beliefs about taking medication (1×/wk for 7 wk) to improve medication adherence.
Level 1b	Daley et al. (2014)	Participants: N = 76 (M age = 71 yr; 65% male) Setting: Hospital and home (United Kingdom) Intervention: Routine care plus 1:1 adherence therapy sessions at home that included assessment of medications, problem solving of nonadherence issues, reflection on experience with medication, and discussion of beliefs regarding taking medication, 1×/wk for 7 wk. Outcome measures: MMAS–4
B: Moderate	Recommendation: Practitioners could consider using community-based physical activity interventions incorporating multimodal exercise programs or group tango dancing (6–12 mo) to improve IADL participation and function.
Level 1b	Foster et al. (2013)	Participants: N = 62 (M age = 69 yr; 58% male) Setting: Community (United States) Intervention: Dance classes consisting of progressive Argentine tango lessons with participants with PD paired with people without PD, 1 hr 2×/wk for 12 mo. Outcome measures: ACS Current, % Retained, and New Instrumental Activities scores
Level 2b	Nascimento et al. (2014)	Participants: N = 42 (M age = 67 yr; 50% male) Setting: Community (Brazil) Intervention: Mild- to moderate-intensity multimodal exercise program consisting of muscular resistance, balance and motor coordination, and aerobic exercises, 1 hr 3×/wk for 6 mo. Outcome measures: IPAQ Brazilian version
B: Moderate	Recommendation: Practitioners could consider using tailored home-based occupational therapy (10 wk) to improve IADL participation.
Level 1b	Sturkenboom et al. (2014)	Participants: N = 191 (M age = 70.5 yr; 62% male) Setting: Home (the Netherlands) Intervention: Tailored home-based occupational therapy according to the Dutch guidelines for people with PD, including advice and strategy training in activities and adaptation of tasks, daily routines, or environment (e.g., assistive devices), depending on complexity of issues to be addressed, a maximum of 16 1-hr sessions over 10 wk. Outcome measures: ACS % Instrumental Activities Retained

Note. All studies had statistically significant positive outcomes related to the interventions discussed. ACS = Activity Card Sort; IADLs = instrumental activities of daily living; IPAQ = International Physical Activity Questionnaire; MDS–UPDRS = Movement Disorder Society–Unified Parkinson’s Disease Rating Scale; MMAS–4 = Morisky Medication Adherence Scale–4; PASS = Physical Activity Status Scale; PD = Parkinson’s disease; SOS = Systematic Screening of Handwriting Difficulties.

Table 3.

Clinical Recommendations and Supporting Evidence: Interventions to Address Participation in Education, Work, Volunteering, Leisure, and Social Participation Among People With PD

Grade/Evidence Level	Citation	Intervention Details
B: Moderate	Recommendation: Practitioners could consider using community-based tango dance class (2×/wk for 12 mo) to increase the number of new social activities.
Level 1b	Foster et al. (2013)	Participants: N = 62 (M age = 69 yr; 58% male) Setting: Community (United States) Intervention: Dance classes consisting of progressive Argentine tango lessons with participants with PD paired with people without PD, 1 hr 2×/wk for 12 mo. Outcome measures: Activity Card Sort Current, % Retained, and New Social Activities scores

Note. This study had statistically significant positive outcomes related to the intervention discussed. PD = Parkinson’s disease.

For the purposes of this Practice Guideline, we report recommendations graded A, B, and D, the grades that best support clinical decision making:

A: There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Strong evidence was found that the intervention improves important outcomes and that benefits substantially outweigh harms.

B: There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

D: It is recommended that occupational therapy practitioners not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits. In these reviews, we did not find Grade D evidence.

These grades are reported in Tables 1–3 and designated with green, indicating should consider if appropriate (A), or yellow, indicating could consider if appropriate (B). None of the studies included in these reviews reported adverse events or harms related to the interventions evaluated (D).

The complete findings from the systematic reviews can be found in the applicable articles in the American Journal of Occupational Therapy (Boone et al., 2021; Doucet et al., 2021; Foster et al., 2021) and the Critically Appraised Topic (Reiling Ott & Kolodziejczak, 2020). As always, practitioners’ clinical decisions should be informed by the evidence presented in this Practice Guideline, in combination with their clinical experience and the client’s particular goals.

Translating Clinical Recommendations Into Practice

Clinical Reasoning Considerations

The purpose of clinical practice guidelines is to help practitioners translate pertinent research findings from systematic reviews into practice. Very rarely will practitioners find an evidence-based intervention that perfectly fits their clinical setting and the client’s specific needs. Occupational therapy practitioners need to consider several questions as they evaluate the research and consider whether they can use an intervention, or adapt it in a well-reasoned way, to exact meet the client’s needs (Highfield et al., 2015):

Exactly what intervention do I need to provide?

What types of client outcomes am I looking for?

Do the studies I’ve located provide enough detail on the intervention so that I know what to do and how to do it?

How well do the conditions in which I will provide the intervention match those in the studies?

What are the demographic characteristics (e.g., age, gender, diagnosis, comorbidities) of the participants in the research studies?

In which setting (e.g., inpatient, home, community, school) did the studies take place?

Do any contextual factors (e.g., resources, policies) that are different from those in the studies influence my ability to provide the intervention?

How flexible is the intervention, and how much can I modify or adapt it?

If my setting or client population differs from those of the studies, can I modify or adapt the intervention without changing its integrity?

If I modify or adapt the intervention, what client characteristics (e.g., comorbidities) do I need to consider?

Can I be proactive and plan how to modify or adapt the intervention before I start implementing it?

Can I make minimal changes to the intervention, such as reordering the content of the sessions, or does the need for substantial changes indicate I should select another intervention?

To modify or adapt evidence-based interventions in practice, practitioners must plan and proactively think through the changes they need to make to fit the intervention to the client and practice setting. In addition, they must document how and why they altered the researched intervention so others in their setting know how to implement the intervention and why the changes were made. If an intervention must be adapted extensively, it may not be the right fit for the situation. When practitioners adapt an intervention, it is no longer evidence based, but rather evidence informed. If extensive adaptations to the intervention are necessary, the intervention is probably not right for the client or setting. If the practitioner finds that the intervention does not suit the client, they should not use that intervention. Clinical interventions should be as similar as possible to the interventions used in the research.

Clinical Case Studies and Algorithms

The case studies in this section illustrate how occupational therapy practitioners can translate evidence from the systematic reviews to professional practice when collaborating with people with PD across the continuum of care. Each case study highlights interventions that are supported by evidence and expert opinion. The case studies contain decision-making algorithms developed by the authors and AOTA staff on the basis of the clinical recommendations; each algorithm includes decision points and actions for practitioners to take. We provide a CPT ^® billing code 1 (American Medical Association, 2021) for each intervention to aid translation to professional practice.

Occupational therapy practitioners can use these algorithms to inform their own clinical decision making, as appropriate. Practitioners must consider each potential intervention in relation to the client’s individual goals, interests, habits, routines, and environment and choose interventions that strongly align with or are supportive of these factors in the context of the client’s occupational profile. It is important to note that the algorithms in this Practice Guideline present simplified examples of the decision-making processes occupational therapy practitioners might use to address their specific clients’ goals.

Case Study 1: Steven

Occupational Profile

Steven is a 57-yr-old man who was diagnosed with PD 3 yr ago. He has relatively mild bilateral motor signs and intact balance. He reports night terrors and racing thoughts that interfere with his ability to fall asleep and stay asleep. He is having trouble with the IADL tasks of cleaning and cooking because of fatigue and excessive daytime sleepiness. Steven reports feeling socially isolated after his recent retirement and recognizes that he is not being as physically or socially active as he should be to manage his symptoms, stay busy, and be engaged with others. His strengths include his religious faith and his family, who live nearby and provide emotional support. Steven is motivated to return to exercise, engage socially in his community, and learn strategies to manage his sleep difficulties and reduce his fatigue.

Occupational Therapy Initial Evaluation and Findings

On the basis of Steven’s primary complaints of disrupted sleep and fatigue, the occupational therapist administered the Parkinson’s Disease Sleep Scale second edition (PDSS–2; Trenkwalder et al., 2011) and the Fatigue Severity Scale (Friedman et al., 2010) to quantify the sleep disruption and fatigue he was experiencing. The therapist created a nonstandardized sleep log for Steven to track his bedtime, wake time, and estimated number of times he woke during the night. The therapist also used the Activity Card Sort (Baum & Edwards, 2008) and the Canadian Occupational Performance Measure (COPM; Law et al., 2014) to develop an occupational profile (AOTA, 2021), support Steven in setting client-centered goals, inform intervention planning, and monitor change in Steven’s perceived activity participation and occupational performance during treatment. Steven’s COPM scores indicated he was experiencing considerable disruption in his performance of and participation in IADLs and leisure and social activities because of disrupted sleep and significant fatigue. Table 4 summarizes Steven’s initial assessment results.

Table 4.

Steven’s Initial Assessment Results

Assessment	Results
Parkinson’s Disease Sleep Scale (Trenkwalder et al., 2011)	Steven’s composite score of 46/60 indicates significant disruptions to sleep resulting in daytime sleepiness.
Fatigue Severity Scale (Friedman et al., 2010)	Steven’s total score of 47/63 suggests significant fatigue (i.e., >36). Steven reports that his fatigue affects his motivation to exercise and capacity for sustained participation in homemaking tasks. He strongly agrees that fatigue decreases his motivation and physical functioning, interferes with certain duties and responsibilities, and is among his 3 most disabling symptoms.
Sleep journal	Steven initiates the sleep log during his initial assessment in the clinic. He reports that the previous evening, he attempted to go to bed at 11:00 p.m., was unable to fall asleep until 1:00 a.m., and had four episodes of night waking. His average wake time is 7:00 a.m.
Canadian Occupational Performance Measure (Law et al., 2014)	Steven rates his performance of and satisfaction with the following self-identified occupations on a 10-point scale (1 = not able to do it or not satisfied at all, 10 = able to do extremely well or extremely satisfied):• Meal preparation: Performance = 4, Satisfaction = 4• Cleaning tasks: Performance = 3, Satisfaction = 4• Computer use: Performance = 2, Satisfaction = 3• Social engagement: Performance = 4, Satisfaction = 3• Physical activity level: Performance = 4, Satisfaction = 3• Average Performance score = 3.4• Average Satisfaction score = 3.4
Activity Card Sort (Baum & Edwards, 2008)	Steven reports reductions in activity participation since being diagnosed with PD in each of the activity domains (percentages indicate retention of participation):• Instrumental = 72%• Low-Demand Leisure = 90%• High-Demand Leisure = 50%• Social = 60%He specifically reports less frequently completing household tasks, going out to destinations in the community, walking and exercising, communicating with friends and family, attending social events, and attending church and volunteer activities. He would like to increase his participation in these activities.

On the basis of Steven’s assessment results, the occupational therapist and Steven developed the following treatment goals:

Steven will improve his ability to fall asleep and report a decrease in nightly sleep disruptions with use of mindfulness and complex exercise.

Steven will report a reduction in severity of fatigue with use of fatigue management strategies and improvements in physical activity and sleep.

Steven will demonstrate the ability to use computer applications of his choice to enhance social participation using compensatory strategies and aids to support computer use.

Steven will complete meal preparation and cleaning tasks using task-oriented and fatigue management strategies.

Steven will demonstrate engagement in physical activity 5 of 7 days per week by discharge to improve sleep and promote symptom management, tracking his activity with a fitness log.

Occupational Therapy Interventions

Steven received occupational therapy in a multidisciplinary center specializing in outpatient occupational, physical, and speech therapy for people with neurological movement disorders. He attended sessions 3 times per week for 8 wk. The occupational therapist selected a tailored goal-oriented multicomponent approach to intervention (Sturkenboom et al., 2014) that included self-management techniques to address Steven’s sleep, fatigue, and physical activity levels and task-specific training and compensatory strategies to support meal preparation, cleaning, and email use.

The occupational therapist had background and training in use of cognitive–behavioral therapy techniques and mindfulness meditation and maintained a network of community engagement opportunities for client referral. The occupational therapist collaborated with Steven’s physical therapist, who assessed his balance, to select appropriate exercise options for Steven to include in the behavioral change intervention.

Mindfulness Meditation–Based Complex Exercise Program

After reviewing the sleep algorithm in Figure 1, the occupational therapy practitioner selected a mindfulness meditation–based complex exercise program (Son & Choi, 2018) to address Steven’s sleep, fatigue, and physical activity goals (97530—Therapeutic activities). The program included strength, endurance, coordination, and flexibility exercises combined with meditation exercises. Steven’s training included warm-up stretches, elastic band exercises for the upper and lower extremities, ball exercises, and breath and mindfulness meditation training.

ParkFit

The occupational therapist, after reviewing and guided by the functional mobility algorithm in Figure 2, selected the ParkFit program (van Nimwegen et al., 2013) to support and improve Steven’s motivation to engage in physical activity. ParkFit is an individually tailored, multifaceted behavioral change program designed to target and increase physical activity levels (97350—Therapeutic activities). The ParkFit program provides clients with an educational brochure about physical activity and PD, personalized activity coaching sessions, individualized goal setting, coping planning, and motivation to participate in exercise. The therapist collaborated with Steven to create a daily plan for physical activity to improve his compliance with the home exercise program and increase his activity level. The therapist also gave Steven an ambulatory monitor to provide feedback on his daily physical activity levels.

Community Tango Class

The occupational therapist referred Steven to a local community tango class to support his goals for physical activity, social engagement, and IADL participation (Foster et al., 2013). The occupational therapist encouraged Steven to communicate with the tango instructor via email to practice his email skills. Steven signed up for the class and reported weekly participation beginning in Week 3 of his occupational therapy treatment.

Task-Specific Training, Self-Management, and Compensatory Strategies

The occupational therapist incorporated several individually tailored approaches to address Steven’s fatigue, social engagement, and IADL goals (Sturkenboom et al., 2014; 97535—Self-care/home management). The occupational therapist trained Steven to use email and the internet to communicate with former colleagues, friends, and family and to find out about local activities and events. The therapist provided task-specific training incorporating use of a variety of keyboards, mouse types, and accessibility settings to optimize Steven’s performance. Steven practiced sending emails to the therapist, family, and friends during his occupational therapy sessions, and the occupational therapist provided feedback.

The occupational therapist educated Steven in the use of fatigue management strategies (Kluger, 2017). The practitioner stressed the use of planning and pacing strategies to prevent extreme fatigue and trained Steven trained to use a daily planner to organize his day and balance activities and rest. The therapist educated Steven in the use of strategies to simplify meal preparation and cleaning tasks.

Outcomes

Steven attended 22 of 24 outpatient occupational therapy sessions. He improved in all outcome measures and met all of his occupational therapy treatment goals. Steven’s PDSS–2 scores and sleep journal showed a reduction in fragmented sleep, improved ability to manage his fatigue and daytime sleepiness, and clinically meaningful improvements (≥2 points) in COPM Performance and Satisfaction scores. Table 5 summarizes his outcomes.

Table 5.

Steven’s Discharge Assessment Results

Assessment	Outcome
Parkinson’s Disease Sleep Scale (Trenkwalder et al., 2011	Steven reports improvement in his sleep, and his composite score has decreased from 46/60 to 32/60. He reports being better able to fall asleep and having fewer sleep disruptions during the night.
Fatigue Severity Scale (Friedman et al., 2010)	Steven’s total score has improved from 47/63 to 34/63, indicating that his fatigue is now less debilitating (i.e., 36). Steven is excited to report that he no longer struggles with fatigue in the afternoon when trying to prepare meals.
Sleep journal	Steven’s sleep journal shows an average of 1 to 2 disruptions in sleep per night for the past week and no difficulty falling asleep.
Canadian Occupational Performance Measure (Law et al., 2014)	Steven reports improvement in all self-identified problem areas. His average scores for Performance increased from 3.4/10 to 7/10 and for Satisfaction from 3.4/10 to 8.4/10.• Meal preparation: Performance = 7, Satisfaction = 8• Cleaning tasks: Performance = 8, Satisfaction = 8• Computer use: Performance = 7, Satisfaction = 9• Social engagement: Performance = 6, Satisfaction = 8• Physical activity level: Performance = 7, Satisfaction = 9
Activity Card Sort (Baum & Edwards, 2008)	Steven’s % Activity Retention scores improved in all activity domains, showing that he has regained some of the activities that he had given up or participated in less since his diagnosis:• Instrumental = 85%• Low-Demand Leisure = 95%• High-Demand Leisure = 80%• Social = 78%He anticipates continuing to regain meaningful activities and to try new things he did not have time for while working.

Case Study 2: Linda

Occupational Profile

Linda is a 70-yr-old woman who was diagnosed with PD 10 yr ago. She recently received multidisciplinary inpatient rehabilitation after she sustained an injury from a fall during a bout of freezing of gait, and she has been referred for home-based outpatient occupational therapy services after discharge (Doucet et al., 2021). Linda lives with her partner, whom she describes as supportive and helpful. She continues to work per diem as a social worker and demonstrates good insight into her strengths and challenges (AOTA, 2021). She is motivated to learn exercises, adaptations, and strategies to improve her function, maintain her independence, and manage the progression of her PD symptoms.

Occupational Therapy Initial Evaluation and Findings

During the evaluation, Linda reported fear of falling and concern for her safety during kitchen mobility. She demonstrated upper extremity tremor, bradykinesia, and rigidity and reported difficulty using her arms and hands in daily tasks, resulting in extended time needed for dressing tasks and difficulty with fine motor coordination. She reported needing occasional assistance from her partner to thread her arms into jacket sleeves and don and doff garments over her head; the growing need for assistance from her partner makes her feel “dependent.” She demonstrated micrographia when completing clinical forms and complained of difficulty reading her own writing when making lists at home. She reported medication management problems; she often missed her midday dose of dopaminergic medications when she was not at home, which resulted in it wearing off and increased episodes of freezing of gait. She also reported decreased participation in meal preparation tasks because of her episodes of freezing of gait and related fear of falling.

The occupational therapist administered the Activities-specific Balance Confidence Scale (Powell & Myers, 1995) to further explore Linda’s fear of falling. The therapist used the Patient-Specific Functional Scale (Stratford et al., 1995) to identify and quantify Linda’s activity limitations and assist in setting client-centered goals. Linda identified zipper manipulation, jewelry fastening, upper body dressing, handwriting, and medication management as important areas for improvement. The therapist used a timed assessment of upper body dressing and jewelry fastening to provide an objective baseline measure of ADL performance. The therapist also provided Linda with a log to record how long it took her to perform these tasks on a daily basis. Linda’s scores on these measures indicate reduced efficiency and decreased independence in ADL tasks. Table 6 summarizes Linda’s initial assessment results.

Table 6.

Linda’s Initial Assessment Results

Assessment	Results
Patient-Specific Functional Scale (Stratford et al., 1995)	Linda rates her self-identified functional problem areas on an 11-point scale (0 = not able to perform the task, 10 = able to perform the task as before):• Zipper manipulation = 4• Jewelry fastening = 3• Upper body dressing = 4• Handwriting = 4• Medication management = 5• Total score = 4.2
Timed activities of daily living tasks	The practitioner performs a timed task analysis of fastening a necklace, donning a shirt overhead, and manipulating a jacket zipper:• Linda demonstrates 3 failed attempts to fasten the clasp of her favorite necklace, completing her final trial in 2 min 40 s.• She demonstrates difficulty threading her shirt over her head and trunk, completing the task in 3 min 27 s with minimal assist from the practitioner to pull the back of the shirt over her trunk.• Linda is able to independently zip her jacket in 2 min 15 s with increased frustration.
Goal attainment scaling	The practitioner uses goal attainment scaling in setting the goal of decreasing Linda’s freezing of gait during meal preparation:• –2, much less than expected level of performance: Linda will complete meal prep tasks using strategies and environmental cues to manage episodes of freezing of gait in 0 out of 4 instances in 4 wk.• –1, less than expected level: Linda will complete meal prep tasks using strategies and environmental cues to manage episodes of freezing of gait in 1 out of 4 instances in 4 wk.• 0, expected level: Linda will complete meal prep tasks using strategies and environmental cues to manage episodes of freezing of gait in 2 out of 4 instances in 4 wk.• +1, better than expected level: Linda will complete meal prep tasks using strategies and environmental cues to manage episodes of freezing of gait in 3 out of 4 instances in 4 wk.• +2, much better than expected level: Linda will complete meal prep tasks using strategies and environmental cues to manage episodes of freezing of gait in 4 out of 4 instances for 4 wk.
Activities-specific Balance Confidence Scale (Powell & Myers, 1995)	On a scale of 0% (no confidence) to 100% (complete confidence), Linda rates an average of 60% confidence in 16 functional mobility activities, suggesting a strong fear of falling. She notes particularly low confidence in low reaching and walking in her home.

On the basis of Linda’s initial assessment results, the occupational therapist and Linda developed the following goals for treatment:

Linda will demonstrate increased efficiency in dressing tasks with use of large-amplitude, task-specific strategies to support manipulation of clothing and jewelry fasteners.

Linda will demonstrate increased size and legibility in handwriting with use of visual targets and home practice to support participation in work, bill paying, and shopping tasks.

Linda will use strategies and environmental cues to manage three out of four episodes of freezing of gait to prevent falls, reduce fear of falling, and improve safety.

Linda will engage in regular physical activity (at least 40 min, at least 2×/wk) to support symptom management and improve or maintain ADL function and functional mobility.

Linda will demonstrate accurate compliance with her dopaminergic medication regimen 7 out of 7 days per week to support symptom management.

Occupational Therapy Interventions

Linda was referred to home-based outpatient occupational therapy services after discharge from an inpatient stay. Linda’s plan of care includes physical therapy 2×/wk and occupational therapy 3×/wk to continue multidisciplinary care to improve her ADL performance. One occupational therapy session each week is conducted by an occupational therapy assistant. The occupational therapy and physical therapy practitioners collaborate to provide multicomponent interventions to address Linda’s goals. They use task-specific training to address specific problematic ADLs and IADLs (e.g., upper body dressing, handwriting; Foster et al., 2021), exercise to address general ADL function (Doucet et al., 2021), and environmental modifications and external cues to address functional mobility (Foster et al., 2014). In addition, the occupational therapy team uses a cognitive–behavioral approach to address medication adherence (Daley et al., 2014).

Five days per week of therapy services was a departure from the norm, but the therapy team felt that research evidence (Doucet et al., 2021 ; Foster et al., 2021) on the need for intensity and repetition of practice supported a more intensive plan of care to increase Linda’s safety and independence. The occupational therapist and physical therapist reviewed the handwriting algorithm in Figure 3 and the ADL algorithm in Figure 4 and collaborated to develop Linda’s plan of care, focusing on different yet complementary aspects of assessment and intervention. Throughout Linda’s care, both practitioners communicated and supported the other practitioner’s instructions and strategies to provide consistent cues to address her freezing of gait and functional mobility (Radder et al., 2017).

Task-Specific Training

The occupational therapy assistant provided training and practice in strategies to support Linda’s handwriting performance, including the use of visual stimuli (e.g., colored target zones, lines) to provide external cues to support writing size and legibility (Nackaerts et al., 2016; Ziliotto et al., 2015; 97530—Therapeutic activities). After two 30-min sessions, the occupational therapy assistant provided Linda with a workbook with hand exercises and writing activities (e.g., cued, free writing, copying shapes, writing a postcard) and recommended Linda practice on her own 1 hr 2×/wk (Collett et al., 2017).

For the first 4 wk, the occupational therapist and physical therapist provided Linda with four 60-min sessions per week of task-specific training using the LSVT BIG^® protocol (Fox et al., 2012; LSVT BIG, n.d.). The goals were to improve Linda’s performance of ADL tasks (zipper manipulation, jewelry fastening, upper body dressing) and kitchen mobility (97112—Neuromuscular reeducation, 97530—Therapeutic activities). During LSVT BIG training, Linda performed exercise and functional tasks while applying large-amplitude strategies to support her performance. In addition, Linda completed exercises, functional components, and carryover tasks at home every day, tracking them in her log.

Medication Adherence Therapy

After obtaining Linda’s prescribed medication regimen from her movement disorder specialist, the occupational therapy assistant addressed medication management with Linda and her partner by reviewing her medication, including her beliefs and attitudes about it (Daley et al., 2014; 97535—Self-care/home management). The assistant provided education on taking medication at the correct time intervals and reassured her that the medication would improve Linda’s symptoms and reduce her freezing of gait and risk of falling. Together they developed practical solutions to improve her adherence, including setting a daily timer on her phone for her midday dose and keeping a small vial of backup pills in her purse for when she is out. Linda collaborated with the assistant to create a medication log to track all her daily doses.

Physical Activity

During a discussion of the importance of exercise for people with PD, Linda mentioned that she had enjoyed doing Wii exercises while in inpatient rehabilitation and that her partner had a Wii system (Nintendo, Kyoto, Japan; see Figure 2). The occupational therapist recommended exercising using the Wii for at least 40 min 2×/wk (Herz et al., 2013).

Figure 1.

Decision-making algorithm for interventions to improve sleep and rest for people with Parkinson’s disease.

Figure 2.

Decision-making algorithm for interventions incorporating physical activity to improve functional mobility for people with Parkinson’s disease.

Figure 3.

Decision-making algorithm for interventions to improve handwriting for people with Parkinson’s disease.

Figure 4.

Decision-making algorithm for interventions to address ADLs for people with Parkinson’s disease.

Environmental Modifications, External Cues, and Functional Mobility Training

To increase Linda’s safety and prevent falls, the occupational therapist performed a home safety evaluation and recommended home modifications such as removing throw rugs, installing grab bars in the bathroom, and rearranging items in closets and cabinets to avoid bending and reaching (97535—Self-care/home management). The occupational therapist and occupational therapy assistant collaborated with the physical therapist to identify the best external cues and movement strategies to reduce Linda’s freezing of gait. Linda practiced using taped lines on the floor as an external cue to support walking through the kitchen doorway without freezing, and she was trained to use marching quarter turns and side stepping to address concerns with turning tasks in kitchen.

Outcomes

Linda met all of her goals for therapy. She demonstrated increased safety and independence in ADLs and IADLs and increased balance confidence, and she performed better than expected on goal attainment scaling for management of freezing of gait episodes during meal preparation activities. She demonstrated significant reduction in time for dressing tasks, reported no longer needing assistance for upper body dressing tasks, and made noticeable improvement in zipper manipulation, jewelry fastening, and handwriting. She demonstrated consistent tracking of her dopaminergic medications with accurate and timely compliance 7 days per week. Table 7 summarizes Linda’s outcomes.

Table 7.

Linda’s Discharge Assessment Results

Assessment	Outcome
Patient-Specific Functional Scale (Stratford et al., 1995)	Linda reports improvement in all activities, resulting in an increase in total score from 4.0/10 to 7.6/10.• Zipper manipulation = 8• Jewelry fastening = 7• Upper body dressing = 8• Handwriting = 8• Medication management = 7• Total score = 7.6
Timed ADL tasks	Linda demonstrates improved fine motor skills during manipulation of clothing and jewelry fasteners, increasing her efficiency in performing ADL tasks.• She is able to fasten her favorite necklace in 30 s.• She is able to don an overhead shirt in 40 s.• She is able to zip her jacket in 22 s.
Goal attainment scaling	Linda completes meal preparation tasks at the better than expected level (+1), successfully managing 3 out of 4 freezing of gait episodes using safety strategies and environmental cues.
Activities-specific Balance Confidence Scale (Powell & Myers, 1995)	Linda rates an average of 75% confidence in 16 functional mobility activities, suggesting a significant reduction in her fear of falling. She notes improved confidence with low reaching and moving in her kitchen when preparing a meal.

Strengths and Limitations of the Current Body of Evidence

There are strengths and limitations related to the current body of evidence in the systematic reviews that informed this practice guideline. Systematic reviews address specific clinical questions that are guided by an a priori protocol for the question development and review process. No systematic review can address all aspects of a topic; authors make many decisions before conducting the review. Additionally, no review is perfect, and even the most careful searches sometimes miss articles. The way to reduce these potential sources of bias is to conduct the review using best-practice methodology.

Strengths

The review authors followed best-practice methodology to the best of their ability at every step of the process—for example, by getting input at all stages from practitioners, researchers, consumers, and experts in the areas included in the reviews. The review questions for the systematic reviews were developed with an intentional focus on occupation-based outcomes. Improvement in these outcomes is the goal of occupational therapy, so the systematic reviews targeted studies reporting occupation-based interventions and outcomes.

Limitations: Gaps in the Evidence

Gaps in knowledge exist when there is insufficient, imprecise, inconsistent, or biased information in the literature about an intervention (Robinson et al., 2011). Gaps also exist when the literature is not sufficient to answer a clinical question.

Lack of research supporting particular interventions does not mean practitioners should not use those interventions. In work with clients, practitioners considering specific interventions when there is not enough evidence to support evidence-based practice should use expert knowledge and their own training and experience to guide practice. In this section, we pinpoint important gaps in evidence for interventions and approaches practitioners may consider using as appropriate.

Occupational therapy practitioners need to think about the elements of evidence-based practice as they evaluate this guideline in light of gaps in the literature related to their clinical practice. Practitioners should consider the following questions when they identify these gaps (Gutenbrunner & Nugraha, 2020):

What evidence exists?

What are the best practices associated with providing services to this client population?

What interventions are contraindicated for this population?

What outcomes am I hoping to achieve with this client?

Does evidence exist in another field or discipline related to interventions and desired outcomes that are within the scope of occupational therapy practice?

What are my client’s preferences and values?

Does my client prefer one intervention over another?

Are available resources, cost, or time influencing my client’s preference?

How might the intervention I am considering affect my client’s performance patterns and roles?

Does my client find the intervention I am considering meaningful?

What experience and expertise do I have that can help guide my decisions?

What types of interventions have I used previously that were effective with similar clients or populations?

What types of interventions have I used previously that were ineffective with similar clients or populations?

What potential risks does the intervention I’m considering pose to my client or this client population?

Will the health care system or organization be supportive of this intervention?

How will I document this intervention?

How will I document the outcomes associated with this intervention?

Is it likely that this intervention will be reimbursed?

The following sections present additional information and common occupational therapy interventions for clients with PD that are not addressed in these guidelines because of a lack of relevant evidence. These sections are based on existing or emerging evidence, expert opinion, or both.

LSVT BIG

LSVT BIG is a popular task-oriented approach to improving movement in people with PD. Participants in LSVT BIG have shown improvements in balance, dexterity, posture, and gait speed (Flood et al., 2020; McDonnell et al., 2018). These motor-related improvements may translate into improved daily function for clients who are interested in the interventions and can tolerate the intensity. Occupational therapy practitioners may recommend additional activities or community programs (e.g., Rock Steady Boxing, n.d.) but should determine their appropriateness for clients and select the method of delivery (e.g., setting, training of professional, skills) to best fit their unique needs.

Nonmotor Impairments

Low vision

Occupational therapy practitioners should screen clients with PD for visual dysfunction and, if warranted, complete a formal evaluation to identify specific deficits. Interventions for low vision can include home safety modifications and strategies to support safe task performance (Savitt & Mathews, 2018).

Cognitive impairment

Occupational therapy practitioners should address cognition with clients with PD as it affects occupational performance and participation. They should assess cognition and provide treatment that matches the client’s cognitive abilities and functional goals. Goal-oriented and strategy-based cognitive interventions may help clients meet their personalized functional goals (e.g., Foster et al., 2018; Hindle et al., 2018; Reuter et al., 2012). In addition, cognitive stimulation therapy may be beneficial for people with PD-related dementia and their care partners (McCormick, McDonald, Vatter, Orgeta, Poliakoff, Smith, & Leroi, 2017; McCormick, McDonald, Vatter, Orgeta, Poliakoff, Smith, Silverdale, et al., 2017).

Occupations

Driving

Because participation in driving carries significant meaning and has an impact on safety, occupational therapy practitioners should screen clients with PD for fitness to drive. Practitioners should also consider the caregiver’s risk impressions (Classen & Alvarez, 2016) and the client’s scores on the Trail Making Test Part B (Arbuthnott & Frank, 2000), Useful Field of View (Edwards et al., 2006), and contrast sensitivity measures when screening to identify at-risk drivers with PD who need a comprehensive driving evaluation (Alvarez & Classen, 2018).

Work performance and employment

Occupational therapy practitioners should assess work-related skills and duties and provide strategies, modifications, and accommodations to support participation in work or productivity. Resources such as the Job Accommodation Network (n.d.) provide occupational therapy practitioners with useful ideas for job accommodations for people with PD.

Sexuality and intimacy

Intimacy and sexual expression are important dimensions of quality of life for people with PD and their partners. Occupational therapy practitioners should ensure a private and comfortable environment to discuss any changes to sexuality and can proactively address sexual health issues by providing information, recognizing and addressing the sexual needs of people with PD, and referring them to specialists (Bronner, 2009).

Care Partner–Oriented Intervention

Care partners are an integral part of the team when providing client-centered care to people with PD, and they often experience significant challenges (e.g., financial, social, work-related, psychological) as they navigate this complex role. Occupational therapy practitioners can support the participatory roles of care partners of people with PD by providing education on home modifications, task adaptations, cuing strategies, handling, equipment use, and fall prevention. They should also directly address the care partner’s well-being by discussing topics such as stress management, engagement in physical activity, communication, social support, respite care, and occupational balance (e.g., yoga [Walter et al., 2018], cognitive–behavioral therapy [Okai et al., 2013]).

Additional Implications for Occupational Therapy

To complement the intervention recommendations provided in Tables 1–3, the sections that follow describe general implications for occupational therapy with people with PD and their care partners based on PD-related evidence and best-practice occupational therapy principles.

Specialized Multidisciplinary Care

The clinical recommendations regarding multidisciplinary inpatient rehabilitation to improve ADL performance are based on the findings of studies conducted in Italy. Although this model of care is not (yet) standard practice in the United States, a consensus of expert opinion is that occupational therapy with people with PD should occur in the context of specialized multidisciplinary care across the continuum of settings and stages. In all settings and countries, occupational therapy practitioners should use their professional reasoning and experiences to determine whether findings on specialized multidisciplinary care interventions can be generalized to the specific individual, family, and context with which they are working.

Client-Centered Goal-Oriented Treatment

Occupational therapy places value on the delivery of client-centered goal-oriented care, and evidence supports the effectiveness of this approach for people with PD (e.g., Cabrera-Martos et al., 2019; Hindle et al., 2018; Sturkenboom et al., 2014). To develop and track personally meaningful functional goals and measure their achievement, occupational therapy practitioners should use comprehensive and standardized tools such as the Canadian Occupational Performance Measure (Law et al., 2014), goal attainment scaling, the Bangor Goal-Setting Interview (Clare et al., 2016), and the Patient-Specific Functional Scale (Stratford et al., 1995).

Occupation-Based Performance Assessment

Assessment of occupation-based outcomes in research on interventions for people with PD continues to be limited. In addition to using self-report measures of function, occupational therapy practitioners should use objective, performance-based measures of occupational performance and participation to further support the profession’s role with this population. Such measures include the Assessment of Motor and Process Skills (Fisher, 2006), the Performance Assessment of Self-Care Skills (Holm & Rogers, 2008), the Executive Function Performance Test (Baum et al., 2016), the Weekly Calendar Planning Activity (Toglia, 2015), and the Continuous Scale Physical Function Test (Cress et al., 1996).

Late-Stage Parkinson’s Disease

A majority of occupational therapy–related intervention research does not include participants in the late or more severe stages of PD (i.e., Hoehn and Yahr Stages 4 and 5 dementia). Occupational therapy practitioners are often involved in the care of such individuals and offer valuable services, such as maintaining safety of clients and care partners; maximizing comfort; providing opportunities for meaningful occupational engagement; providing caregiver training; planning for posture, positioning, and pressure care; and assisting in end-of-life planning (Aragon & Kings, 2018).

Summary

This Practice Guideline highlights occupational therapy’s unique contribution to the clinical care of people with PD and their care partners. Clinical recommendations based on the current evidence are provided, and application to clinical practice has been exemplified through case studies and decision-making algorithms. Gaps in the evidence on interventions for this population have been highlighted; occupational therapy practitioners should consider these gaps when treating people with PD and their care partners, and researchers should further investigate these gaps to advance the care of people with PD.

Occupational therapy has a distinct and valuable role in supporting the participation, health, and well-being of people with PD and their care partners. In selecting dynamic interventions, occupational therapy practitioners consider a complex and unique set of factors that influence occupational performance. Practitioners can use this Practice Guideline to integrate their own professional experience and reasoning, their clients’ individual and family preferences, and the best available research evidence to provide the highest quality of care for people with PD and their care partners. As the profession and care of people with PD continue to evolve, occupational therapy will need to remain innovative in service delivery models, increase educational opportunities to best prepare future practitioners, and advance the research evidence to provide best-practice services grounded in evidence, theory, and occupation.

Footnotes

1

Codes shown refer to CPT 2022 (American Medical Association, 2021, CPT 2022 Professional Edition, Chicago: American Medical Association Press) and do not represent all of the possible codes that may be used in occupational therapy evaluation and intervention. After 2022, refer to the current year’s CPT code book for available codes. CPT codes are updated annually and become effective January 1. CPT is a trademark of the American Medical Association. CPT five-digit codes, two-digit codes, modifiers, and descriptions are copyright © 2022 by the American Medical Association. All rights reserved.

*

Indicates articles included in the systematic reviews.

Acknowledgments

The authors acknowledge and thank the following individuals for their participation in the content review and development of this publication:

Hillary Richardson, MOT, OTR/L, AOTA Practice Manager, Knowledge Translation, Evidence-Based Practice and Practice Improvement, for her contributions related to knowledge translation and algorithm development.

Practice Guideline Series Editors

Deborah Lieberman, MHSA, OTR/L, FAOTA, Vice President, Practice Improvement, and Staff Liaison to the Commission on Practice, American Occupational Therapy Association, North Bethesda, MD

Susan Cahill, PhD, OTR/L, FAOTA, Director of Evidence-Based Practice, American Occupational Therapy Association, North Bethesda, MD

Practice Guideline Editor and Research Methodologist

Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington

Reviewers

Jamie Archer, MOT, OTR/L; Lisa Carson, OTD, OTR/L; Heather J. Cianci, PT, MS, GCS; Barbara M. Doucet, PhD, LOTR; Joellyn Fox, DPT; Ingrid Franc, PhD, LOTR; Darla Freeman, SLPD, CCC-SLP; Jennifer Goldman, MD, MS; Bernadette Kosir, OTR/L; Kelli Reiling Ott, OTD, OTR/L, MSCS; Chuck Willmarth, CAE; Lance Wilson, MSS, LSW, C-SWHC, ASW-G

The authors acknowledge the following individuals for their contributions to the evidence-based systematic review: Jamie Archer, MOT, OTR/L; Anna E. Boone, MSOT, PhD, OTR/L; Lisa Carson, OTD, OTR/L; Barbara M. Doucet, PhD, LOTR; Erin Foster, PhD, OTD, OTR/L; Ingrid Franc, PhD, LOTR; Whitney Henderson, MOT, OTR/L, OTD; Elizabeth G. Hunter, PhD, OTR/L; Sherry Kolodziejczak, MS, OTR/L, FEW, PAMC, cNDT; Kelli Reiling Ott, OTD, OTR/L, MSCS.

Appendix: Overview of the Systematic Review Methods and Findings

The systematic reviews completed for this Practice Guideline were conducted according to the Cochrane Collaboration methodology (Higgins et al., 2019) and are reported consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).

References

*Advocat

Enticott

Vandenberg

Hassed

Hester

, & Russell

(2016). The effects of a mindfulness-based lifestyle program for adults with Parkinson’s disease: A mixed methods, wait list controlled randomised control study. BMC Neurology , 16 , 166. https://doi.org/10.1186/s12883-016-0685-1

Alvarez

, & Classen

(2018). Driving with Parkinson’s disease: Cut points for clinical predictors of on-road outcomes. Canadian Journal of Occupational Therapy , 85 , 232–241. https://doi.org/10.1177/0008417418755458

American Medical Association. (2021). Current Procedural Terminology (CPT®) 2022 professional edition.

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy , 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

American Occupational Therapy Association. (2021). The Association—Improve your documentation and quality of care with AOTA’s updated Occupational Profile Template. American Journal of Occupational Therapy , 75 , 7502420010. https://doi.org/10.5014/ajot.2021.752001

Aragon

, & Kings

(2018). Occupational therapy for people with Parkinson’s: Best practice guidelines (2nd ed.). Royal College of Occupational Therapists.

Arbuthnott

, & Frank

(2000). Trail Making Test, Part B as a measure of executive control: Validation using a set-switching paradigm. Journal of Clinical and Experimental Neuropsychology , 22 , 518–528. https://doi.org/10.1076/1380-3395(200008)22:4;1-0;FT518

Baum

, & Edwards

D. F.

(2008). Activity Card Sort (2nd ed.). AOTA Press.

Baum

C. M.

Wolf

T. J.

Wong

A. W. K.

Chen

C. H.

Walker

Young

A. C.

, . . . Heinemann

A. W.

(2016). Validation and clinical utility of the Executive Function Performance Test in persons with traumatic brain injury. Neuropsychological Rehabilitation , 27 , 603–617. https://doi.org/10.1080/09602011.2016.1176934

10.

Ben-Joseph

Marshall

C. R.

Lees

A. J.

, & Noyce

A. J.

(2020). Ethnic variation in the manifestation of Parkinson’s disease: A narrative review. Journal of Parkinson’s Disease , 10 , 31–45. https://doi.org/10.3233/JPD-191763

11.

Boone

Henderson

, & Hunter

E. G.

(2021). Role of occupational therapy in facilitating participation among caregivers of people with Parkinson’s disease. American Journal of Occupational Therapy , 75 , 7503190010. https://doi.org/10.5014/ajot.2021.046284

12.

Bronner

(2009). Practical strategies for the management of sexual problems in Parkinson’s disease. Parkinsonism and Related Disorders , 15(Suppl. 3), S96–S100. https://doi.org/10.1016/S1353-8020(09)70791-6

13.

Cabrera-Martos

Ortiz-Rubio

Torres-Sánchez

Rodríguez-Torres

López-López

, & Valenza

M. C.

(2019). A randomized controlled study of whether setting specific goals improves the effectiveness of therapy in people with Parkinson’s disease. Clinical Rehabilitation , 33 , 465–472. https://doi.org/10.1177/0269215518815217

14.

Clare

Nellis

, & Kudlicka

(2016). The Bangor Goal-Setting Interview (Version 2). University of Exeter Centre for Research in Ageing and Cognitive Health. https://medicine.exeter.ac.uk/media/universityofexeter/schoolofpsychology/reach/documents/The_Bangor_Goal-Setting_Interview_Version_2.2_Manual_(BGSI_v.2.2)_March_2022.pdf

15.

Classen

, & Alvarez

(2016). Caregivers’ impressions predicting fitness to drive in persons with Parkinson’s. OTJR: Occupation, Participation and Health , 36 , 5–13. https://doi.org/10.1177/1539449215601117

16.

*Collett

Franssen

Winward

Izadi

Meaney

Mahmoud

, . . . Dawes

(2017). A long-term self-managed handwriting intervention for people with Parkinson’s disease: Results from the control group of a Phase II randomized controlled trial. Clinical Rehabilitation , 31 , 1636–1645. https://doi.org/10.1177/0269215517711232

17.

Cress

M. E.

Buchner

D. M.

Questad

K. A.

Esselman

P. C.

DeLateur

B. J.

, & Schwartz

R. S.

(1996). Continuous-scale physical functional performance in healthy older adults: A validation study. Archives of Physical Medicine and Rehabilitation , 77 , 1243–1250. https://doi.org/10.1016/s0003-9993(96)90187-2

18.

*Daley

D. J.

Deane

K. H.

Gray

R. J.

Clark

A. B.

Pfeil

Sabanathan

, . . . Myint

P. K.

(2014). Adherence therapy improves medication adherence and quality of life in people with Parkinson’s disease: A randomised controlled trial. International Journal of Clinical Practice , 68 , 963–971. https://doi.org/10.1111/ijcp.12439

19.

*da Silva Souza

M. F.

Ribeiro Bacha

J. M.

Guedes da Silva

Beline de Freitas

Torriani-Pasin

, & Pompeu

J. E.

(2018). Effects of virtual rehabilitation on cognition and quality of life of patients with Parkinson’s disease. Fisioterapia em Movimento , 31 , e003112. https://doi.org/10.1590/1980-5918.031.ao12

20.

*Demonceau

Maquet

Jidovtseff

Donneau

A. F.

Bury

Croisier

J. L.

, . . . Garraux

(2017). Effects of twelve weeks of aerobic or strength training in addition to standard care in Parkinson’s disease: A controlled study. European Journal of Physical and Rehabilitation Medicine , 53 , 184–200. https://doi.org/10.23736/S1973-9087.16.04272-6

21.

Doucet

B. M.

Franc

, & Hunter

E. G.

(2021). Interventions within the scope of occupational therapy to improve activities of daily living, rest, and sleep in people with Parkinson’s disease: A systematic review. American Journal of Occupational Therapy , 75 , 7503190020. https://doi.org/10.5014/ajot.2021.048314

22.

ECRI. (2021, November 19). ECRI Institute opens access to clinical practice guidelines [News release]. https://www.ecri.org/press/ecri-institute-opens-access-to-clinical-practice-guidelines

23.

Edwards

J. D.

Ross

L. A.

Wadley

V. G.

Clay

O. J.

Crowe

Roenker

D. L.

, & Ball

K. K.

(2006). The Useful Field of View test: Normative data for older adults. Archives of Clinical Neuropsychology , 21 , 275–286. https://doi.org/10.1016/j.acn.2006.03.001

24.

*Ferrazzoli

Ortelli

Zivi

Cian

Urso

Ghilardi

M. F.

, . . . Frazzitta

(2018). Efficacy of intensive multidisciplinary rehabilitation in Parkinson’s disease: A randomised controlled study. Journal of Neurology, Neurosurgery, and Psychiatry , 89, 828–835. https://doi.org/10.1136/jnnp-2017-316437

25.

Fisher

A. G.

(2006). Assessment of Motor and Process Skills. Vol. 1: Development, standardization, and administration manual (6th ed.). Three Star Books.

26.

Flood

M. W.

O’Callaghan

B. P. F.

Diamond

Liegey

Hughes

, & Lowery

M. M.

(2020). Quantitative clinical assessment of motor function during and following LSVT-BIG^® therapy. Journal of Neuroengineering and Rehabilitation , 17 , 92. https://doi.org/10.1186/s12984-020-00729-8

27.

Foster

E. R.

Bedekar

, & Tickle-Degnen

(2014). Systematic review of the effectiveness of occupational therapy–related interventions for people with Parkinson’s disease. American Journal of Occupational Therapy , 68 , 39–49. https://doi.org/10.5014/ajot.2014.008706

28.

Foster

E. R.

Carson

L. G.

Archer

, & Hunter

E. G.

(2021). Occupational therapy interventions for instrumental activities of daily living for adults with Parkinson’s disease: A systematic review. American Journal of Occupational Therapy , 75 , 7503190030. https://doi.org/10.5014/ajot.2021.046581

29.

*Foster

E. R.

Golden

Duncan

R. P.

, & Earhart

G. M.

(2013). Community-based Argentine tango dance program is associated with increased activity participation among individuals with Parkinson’s disease. Archives of Physical Medicine and Rehabilitation , 94 , 240–249. https://doi.org/10.1016/j.apmr.2012.07.028

30.

Foster

E. R.

Spence

, & Toglia

(2018). Feasibility of a cognitive strategy training intervention for people with Parkinson’s disease. Disability and Rehabilitation , 40 , 1127–1134. https://doi.org/10.1080/09638288.2017.1288275

31.

Fox

Ebersbach

Ramig

, & Sapir

(2012). LSVT LOUD and LSVT BIG: Behavioral treatment programs for speech and body movement in Parkinson disease. Parkinson’s Disease , 2012 , 391946. https://doi.org/10.1155/2012/391946

32.

*Frazzitta

Bertotti

Riboldazzi

Turla

Uccellini

Boveri

, . . . Maestri

(2012). Effectiveness of intensive inpatient rehabilitation treatment on disease progression in parkinsonian patients: A randomized controlled trial with 1-year follow-up. Neurorehabilitation and Neural Repair , 26 , 144–150. https://doi.org/10.1177/1545968311416990

33.

*Frazzitta

Maestri

Bertotti

Riboldazzi

Boveri

Perini

, . . . Ghilardi

M. F.

(2015). Intensive rehabilitation treatment in early Parkinson’s disease: A randomized pilot study with a 2-year follow-up. Neurorehabilitation and Neural Repair , 29 , 123–131. https://doi.org/10.1177/1545968314542981

34.

*Frazzitta

Maestri

Ferrazzoli

Riboldazzi

Bera

Fontanesi

, . . . Ghilardi

M. F.

(2015). Multidisciplinary intensive rehabilitation treatment improves sleep quality in Parkinson’s disease. Journal of Clinical Movement Disorders , 2 , 11. https://doi.org/10.1186/s40734-015-0020-9

35.

*Frazzitta

Maestri

Ghilardi

M. F.

Riboldazzi

Perini

Bertotti

, . . . Comi

(2014). Intensive rehabilitation increases BDNF serum levels in parkinsonian patients: A randomized study. Neurorehabilitation and Neural Repair , 28 , 163–168. https://doi.org/10.1177/1545968313508474

36.

Friedman

J. H.

Alves

Hagell

Marinus

Marsh

Martinez-Martin

, . . . Schrag

(2010). Fatigue rating scales critique and recommendations by the Movement Disorders Society task force on rating scales for Parkinson’s disease. Movement Disorders , 25 , 805–822. https://doi.org/10.1002/mds.22989

37.

Fullard

M. E.

Thibault

D. P.

Hill

Fox

Bhatti

D. E.

Burack

M. A.

, . . . Willis

A. W.

; Parkinson Study Group Healthcare Outcomes and Disparities Working Group. (2017). Utilization of rehabilitation therapy services in Parkinson disease in the United States. Neurology , 89 , 1162–1169. https://doi.org/10.1212/WNL.0000000000004355

38.

GBD 2016 Parkinson’s Disease Collaborators. (2018). Global, regional, and national burden of Parkinson’s disease, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology , 17 , 939–953. https://doi.org/10.1016/S1474-4422(18)30295-3

39.

*Goodwin

V. A.

Richards

S. H.

Henley

Ewings

Taylor

A. H.

, & Campbell

J. L.

(2011). An exercise intervention to prevent falls in people with Parkinson’s disease: A pragmatic randomised controlled trial. Journal of Neurology, Neurosurgery, and Psychiatry , 82 , 1232–1238. https://doi.org/10.1136/jnnp-2011-300919

40.

Gutenbrunner

, & Nugraha

(2020). Decision-making in evidence-based practice in rehabilitation medicine: Proposing a fourth factor. American Journal of Physical Medicine and Rehabilitation , 99 , 436–440. https://doi.org/10.1097/PHM.0000000000001394

41.

*Herz

N. B.

Mehta

S. H.

Sethi

K. D.

Jackson

Hall

, & Morgan

J. C.

(2013). Nintendo Wii rehabilitation (“Wii-hab”) provides benefits in Parkinson’s disease. Parkinsonism and Related Disorders , 19 , 1039–1042. https://doi.org/10.1016/j.parkreldis.2013.07.014

42.

Higgins

J. P. T.

Sterne

J. A. C.

Savović

Page

M. J.

Hróbjartsson

Boutron

, . . . Eldridge

S. A.

(2016). Revised tool for assessing risk of bias in randomized trials. Cochrane Database of Systematic Reviews , 2016(10 Suppl. 1), 29–31. https://doi.org/10.1002/14651858.CD201601

43.

Higgins

J. P. T.

Thomas

Chandler

Cumpston

Page

M. J.

, & Welch

V. A.

(Eds.). (2019). Cochrane handbook for systematic reviews of interventions (2nd ed.). Wiley. https://doi.org/10.1002/9781119536604

44.

Highfield

Hartman

M. A.

Mullen

P. D.

Rodriguez

S. A.

Fernandez

M. E.

, & Bartholomew

L. K.

(2015). Intervention mapping to adapt evidence-based interventions for use in practice: Increasing mammography among African American women. BioMed Research International , 2015 , 160103. https://doi.org/10.1155/2015/160103

45.

Hindle

J. V.

Watermeyer

T. J.

Roberts

Brand

Hoare

Martyr

, & Clare

(2018). Goal-orientated cognitive rehabilitation for dementias associated with Parkinson’s disease—A pilot randomised controlled trial. International Journal of Geriatric Psychiatry , 33 , 718–728. https://doi.org/10.1002/gps.4845

46.

Holm

, & Rogers

(2008). The Performance Assessment of Self- Care Skills (PASS). In Hemphill-Pearson

(Ed.), Assessments in occupational therapy mental health: An integrative approach (pp. 101–112). Slack.

47.

Jansa

, & Aragon

(2015). Living with Parkinson’s and the emerging role of occupational therapy. Parkinson’s Disease , 2015 , 196303. https://doi.org/10.1155/2015/196303

48.

Jansa

Aragon

, & Lundgren-Nilsson

(2011). How people living with Parkinson’s disease in four European countries view occupational therapy. European Neurological Journal , 3 , 1–7.

49.

Job Accommodation Network. (n.d.). About Parkinson’s disease. https://askjan.org/disabilities/Parkinson-s-Disease.cfm

50.

Keus

S. H.

Bloem

B. R.

Verbaan

de Jonge

P. A.

Hofman

van Hilten

B. J.

, & Munneke

(2004). Physiotherapy in Parkinson’s disease: Utilisation and patient satisfaction. Journal of Neurology , 251 , 680–687. https://doi.org/10.1007/s00415-004-0402-7

51.

Kluger

B. M.

(2017). Fatigue in Parkinson’s disease. In Chaudhuri

K. R.

& Titova

(Eds.), Nonmotor Parkinson’s: The hidden face—The many hidden faces (International Review of Neurobiology Vol. 133, pp. 743–768). Academic Press. https://doi.org/10.1016/bs.irn.2017.05.007

52.

Law

Baptiste

Carswell

McColl

M. A.

Polatajko

H. J.

, & Pollack

(2014). Canadian Occupational Performance Measure (5th ed.). CAOT Publications ACE.

53.

*Li

Harmer

Liu

Eckstrom

Fitzgerald

Stock

, & Chou

L. S.

(2014). A randomized controlled trial of patient-reported outcomes with tai chi exercise in Parkinson’s disease. Movement Disorders , 29 , 539–545. https://doi.org/10.1002/mds.25787

54.

LSVT BIG. (n.d.). Training and certification manual. LSVT Global.

55.

Marras

Beck

J. C.

Bower

J. H.

Roberts

Ritz

Ross

G. W.

, . . . Tanner

C. M.

; Parkinson’s Foundation P4 Group. (2018). Prevalence of Parkinson’s disease across North America. NPJ Parkinson’s Disease , 4 , 21. https://doi.org/10.1038/s41531-018-0058-0

56.

Martinez-Martin

Rodriguez-Blazquez

Kurtis

M. M.

Chaudhuri

K. R.

; NMSS Validation Group. (2011). The impact of non-motor symptoms on health-related quality of life of patients with Parkinson’s disease. Movement Disorders , 26 , 399–406. https://doi.org/10.1002/mds.23462

57.

McCormick

S. A.

McDonald

K. R.

Vatter

Orgeta

Poliakoff

Smith

S. J.

, & Leroi

(2017). Psychosocial therapy for Parkinson’s-related dementia: Intervention development. Clinical Interventions in Aging , 12 , 1779–1789. https://doi.org/10.2147/CIA.S143006

58.

McCormick

S. A.

McDonald

K. R.

Vatter

Orgeta

Poliakoff

Smith

Silverdale

M. A.

, . . . Leroi

(2017). Psychosocial therapy for Parkinson’s-related dementia: Study protocol for the INVEST randomised controlled trial. BMJ Open , 7 , e016801. https://doi.org/10.1136/bmjopen-2017-016801

59.

McDonnell

M. N.

Rischbieth

Schammer

T. T.

Seaforth

Shaw

A. J.

, & Phillips

A. C.

(2018). Lee Silverman Voice Treatment (LSVT)–BIG to improve motor function in people with Parkinson’s disease: A systematic review and meta-analysis. Clinical Rehabilitation , 32 , 607–618. https://doi.org/10.1177/0269215517734385

60.

Moher

Liberati

Tetzlaff

, & Altman

D. G.

; PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. PLOS Medicine , 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

61.

*Monticone

Ambrosini

Laurini

Rocca

, & Foti

(2015). In-patient multidisciplinary rehabilitation for Parkinson’s disease: A randomized controlled trial. Movement Disorders , 30 , 1050–1058. https://doi.org/10.1002/mds.26256

62.

Müller

Assmus

Herlofson

Larsen

J. P.

, & Tysnes

O. B.

(2013). Importance of motor vs. non-motor symptoms for health-related quality of life in early Parkinson’s disease. Parkinsonism and Related Disorders , 19 , 1027–1032. https://doi.org/10.1016/j.parkreldis.2013.07.010

63.

*Nackaerts

Heremans

Vervoort

Smits-Engelsman

B. C.

Swinnen

S. P.

Vandenberghe

, . . . Nieuwboer

(2016). Relearning of writing skills in Parkinson’s disease after intensive amplitude training. Movement Disorders , 31 , 1209–1216. https://doi.org/10.1002/mds.26565

64.

*Nascimento

C. M. C.

Ayan

Cancela

J. M.

Gobbi

L. T. B.

Gobbi

, & Stella

(2014). Effect of a multimodal exercise program on sleep disturbances and instrumental activities of daily living performance on Parkinson’s and Alzheimer’s disease patients. Geriatrics and Gerontology International , 14 , 259–266. https://doi.org/10.1111/ggi.12082

65.

National Heart, Lung, and Blood Institute. (2014). Quality assessment tool for before–after (pre–post) studies with no control group. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

66.

Okai

Askey-Jones

Samuel

O’Sullivan

S. S.

Chaudhuri

K. R.

Martin

, . . . David

A. S.

(2013). Trial of CBT for impulse control behaviors affecting Parkinson patients and their caregivers. Neurology , 80 , 792–799. https://doi.org/10.1212/WNL.0b013e3182840678

67.

Oxford Centre for Evidence-Based Medicine. (2009). Oxford Centre for Evidence-Based Medicine: Levels of evidence (March 2009). https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for- evidence-based-medicine-levels-of-evidence-march-2009

68.

*Özgönenel

Çağırıcı

Çabalar

, & Durmuşoğlu

(2016). Use of game console for rehabilitation of Parkinson disease. Balkan Medical Journal , 33 , 396–400. https://doi.org/10.5152/balkanmedj.2016.16842

69.

*Patel

Ojo

Genc

Oravivattanakul

Huo

Rasameesoraj

, . . . Fernandez

H. H.

(2017). A Computerized Cognitive behavioral therapy Randomized, Controlled, pilot trial for insomnia in Parkinson Disease (ACCORD-PD). Journal of Clinical Movement Disorders , 4 , 16. https://doi.org/10.1186/s40734-017-0062-2

70.

*Pedreira

Prazeres

Cruz

Gomes

Monteiro

, & Melo

(2013). Virtual games and quality of life in Parkinson’s disease: A randomized controlled trial. Advances in Parkinson’s Disease , 2 , 97–101. https://doi.org/10.4236/apd.2013.24018

71.

Poewe

(2008). Non-motor symptoms in Parkinson’s disease. European Journal of Neurology , 15(Suppl. 1), 14–20. https://doi.org/10.1111/j.1468-1331.2008.02056.x

72.

*Pompeu

J. E.

Mendes

F. A.

Silva

K. G. D.

Lobo

A. M.

Oliveira

T. P.

Zomignani

A. P.

, & Piemonte

M. E. P.

(2012). Effect of Nintendo Wii™-based motor and cognitive training on activities of daily living in patients with Parkinson’s disease: A randomised clinical trial. Physiotherapy , 98 , 196–204. https://doi.org/10.1016/j.physio.2012.06.004

73.

Powell

L. E.

, & Myers

A. M.

(1995). The Activities-specific Balance Confidence (ABC) Scale. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences , 50A , M28–M34. https://doi.org/10.1093/gerona/50A.1.M28

74.

Preissner

(2014). Occupational therapy practice guidelines for adults with neurodegenerative diseases. AOTA Press.

75.

Qamar

M. A.

Harington

Trump

Johnson

Roberts

, & Frost

(2017). Multidisciplinary care in Parkinson’s disease. International Review of Neurobiology , 132 , 511–523. https://doi.org/10.1016/bs.irn.2017.02.001

76.

Radder

D. L. M.

Sturkenboom

I. H.

van Nimwegen

Keus

S. H.

Bloem

B. R.

, & de Vries

N. M.

(2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of Neuroscience , 127 , 930–943. https://doi.org/10.1080/00207454.2016.1275617

77.

Reiling Ott

, & Kolodziejczak

(2020). Interventions to improve and maintain the performance of and participation in leisure and social participation among adults with Parkinson’s disease: Systematic review of related literature from January 2011–December 2018 [Critically Appraised Topic]. American Occupational Therapy Association.

78.

*Reuter

Mehnert

Leone

Kaps

Oechsner

, & Engelhardt

(2011). Effects of a flexibility and relaxation programme, walking, and Nordic walking on Parkinson’s disease. Journal of Aging Research , 2011 , 232473. https://doi.org/10.4061/2011/232473

79.

Reuter

Mehnert

Sammer

Oechsner

, & Engelhardt

(2012). Efficacy of a multimodal cognitive rehabilitation including psychomotor and endurance training in Parkinson’s disease. Journal of Aging Research , 2012 , 235765. https://doi.org/10.1155/2012/235765

80.

*Ridgel

A. L.

Walter

B. L.

Tatsuoka

Walter

E. M.

Colón-Zimmermann

Welter

, & Sajatovic

(2016). Enhanced Exercise Therapy in Parkinson’s disease: A comparative effectiveness trial. Journal of Science and Medicine in Sport , 19 , 12–17. https://doi.org/10.1016/j.jsams.2015.01.005

81.

*Rios Romenets

Creti

Fichten

Bailes

Libman

Pelletier

, & Postuma

R. B.

(2013). Doxepin and cognitive behavioural therapy for insomnia in patients with Parkinson’s disease—A randomized study. Parkinsonism and Related Disorders , 19 , 670–675. https://doi.org/10.1016/j.parkreldis.2013.03.003

82.

Robinson

K. A.

Saldanha

I. J.

, & McKoy

N. A.

(2011). Development of a framework to identify research gaps from systematic reviews. Journal of Clinical Epidemiology , 64 , 1325–1330. https://doi.org/10.1016/j.jclinepi.2011.06.009

83.

Rock Steady Boxing. (n.d.). I am rock steady. https://www.rocksteadyboxing.org/

84.

Savitt

, & Mathews

(2018). Treatment of visual disorders in Parkinson disease. Current Treatment Options in Neurology , 20 , 30. https://doi.org/10.1007/s11940-018-0519-0

85.

*Schenkman

Ellis

Christiansen

Barón

A. E.

Tickle-Degnen

Hall

D. A.

, & Wagenaar

(2011). Profile of functional limitations and task performance among people with early- and middle-stage Parkinson disease. Physical Therapy , 91 , 1339–1354. https://doi.org/10.2522/ptj.20100236

86.

*Silva-Batista

de Brito

L. C.

Corcos

D. M.

Roschel

De Mello

M. T.

Piemonte

M. E. P.

, . . . Ugrinowitsch

(2017). Resistance training improves sleep quality in subjects with moderate Parkinson’s disease. Journal of Strength and Conditioning Research , 31 , 2270–2277. https://doi.org/10.1519/JSC.0000000000001685

87.

*Son

H. G.

, & Choi

E. O.

(2018). The effects of mindfulness meditation– based complex exercise program on motor and non-motor symptoms, and quality of life in patients with Parkinson’s disease. Asian Nursing Research , 12 , 145–153. https://doi.org/10.1016/j.anr.2018.06.001

88.

Stratford

Gill

Westaway

, & Binkley

(1995). Assessing disability and change on individual patients: A report of a patient specific measure. Physiotherapy Canada , 47 , 258–263. https://doi.org/10.3138/ptc.47.4.258

89.

*Sturkenboom

I. H.

Graff

M. J.

Hendriks

J. C.

Veenhuizen

Munneke

Bloem

B. R.

, & Nijhuis-van der Sanden

M. W.

; OTiP study group. (2014). Efficacy of occupational therapy for patients with Parkinson’s disease: A randomised controlled trial. Lancet Neurology , 13 , 557–566. https://doi.org/10.1016/S1474-4422(14)70055-9

90.

Toglia

(2015). Weekly Calendar Planning Activity. AOTA Press.

91.

Trenkwalder

Kohnen

Högl

Metta

Sixel-Döring

Frauscher

, . . . Chaudhuri

K. R.

(2011). Parkinson’s Disease Sleep Scale—Validation of the revised version PDSS–2. Movement Disorders , 26 , 644–652. https://doi.org/10.1002/mds.23476

92.

U.S. Preventive Services Task Force. (2018). Grade definitions. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

93.

*Vanbellingen

Nyffeler

Nigg

Janssens

Hoppe

Nef

, . . . Bohlhalter

(2017). Home based training for dexterity in Parkinson’s disease: A randomized controlled trial. Parkinsonism and Related Disorders , 41 , 92–98. https://doi.org/10.1016/j.parkreldis. 2017.05.021

94.

van der Marck

M. A.

Kalf

J. G.

Sturkenboom

I. H.

Nijkrake

M. J.

Munneke

, & Bloem

B. R.

(2009). Multidisciplinary care for patients with Parkinson’s disease. Parkinsonism and Related Disorders , 15(Suppl. 3), S219–S223. https://doi.org/10.1016/S1353-8020(09)70819-3

95.

*van Nimwegen

Speelman

A. D.

Overeem

van de Warrenburg

B. P.

Smulders

Dontje

M. L.

, . . . Munneke

; ParkFit Study Group. (2013). Promotion of physical activity and fitness in sedentary patients with Parkinson’s disease: Randomised controlled trial. BMJ , 346 , f576. https://doi.org/10.1136/bmj.f576

96.

*Volpe

Giantin

M. G.

Maestri

, & Frazzitta

(2014). Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: A randomized controlled pilot study. Clinical Rehabilitation , 28 , 1210–1217. https://doi.org/10.1177/0269215514536060

97.

*Wallén

M. B.

Hagströmer

Conradsson

Sorjonen

, & Franzén

(2018). Long-term effects of highly challenging balance training in Parkinson’s disease—A randomized controlled trial. Clinical Rehabilitation , 32 , 1520–1529. https://doi.org/10.1177/0269215518784338

98.

Walter

A. A.

Van Puymbroeck

Hawkins

B. L.

Woschkolup

Urrea-Mendoza

Revilla

F. J.

, & Schmid

A. A.

(2018). Perceived benefits for informal caregivers after an 8-week yoga intervention for people with Parkinson’s disease. American Journal of Recreation Therapy , 16 , 23–29. https://doi.org/10.5055/ajrt.2017.0144

99.

Wright Willis

Evanoff

B. A.

Lian

Criswell

S. R.

, & Racette

B. A.

(2010). Geographic and ethnic variation in Parkinson disease: A population-based study of US Medicare beneficiaries. Neuroepidemiology , 34 , 143–151. https://doi.org/10.1159/000275491

100.

*Ziliotto

Cersosimo

M. G.

, & Micheli

F. E.

(2015). Handwriting rehabilitation in Parkinson disease: A pilot study. Annals of Rehabilitation Medicine , 39 , 586–591. https://doi.org/10.5535/arm.2015.39.4.586