Non-Pharmacological Interventions for People with Parkinson’s Disease: Are We Entering a New Era?

PHYSICAL PERSPECTIVES

In this section, the importance of early delivery of physical training is emphasized in line with the recently published consensus statement by the Parkinson’s Foundation task force [11]. However, several papers in this issue suggest to go one step further. Indeed, a number of promising proactive lifestyle interventions are presented for application in the early phase of clinically manifest PD, and even in the prodromal disease phase; the proposed interventions include dietary mediation therapy in conjunction with physical training. There is also wide acknowledgement for the need to validate accurate instruments to detect subtle motor and non-motor changes and for incorporating the cost-effectiveness of such preventative programs.

Patient compliance is always a central theme in training-based interventions, and in particular the long-term compliance which will be required if non-pharmacological interventions are truly to achieve secondary or tertiary disease prevention in the prodromal phase or clinically manifest phase of PD, respectively. Hence, this section also provides a much-needed and in-depth insight in how to deal with the day-to-day struggles to gain patients’ engagement in exercise therapy. Innovative approaches are suggested by involving patients in training without actual physical effort and to enrich the training experience through action observation and motor imagery techniques.

Prevalent and impactful non-motor symptoms, such as pain [12], but also orthostatic hypotension and urinary incontinence, are often overlooked in standard patient care, and thus remain undertreated, leading to avoidable disability. Yet, various behavioral and other physiotherapeutical interventions, that are delivered by allied health professionals for conditions other than PD, may incur transferable effects. Therefore, it is inspirational to observe the scientific interest and the widening of the scope of physical interventions for PD in this issue.

MENTAL PERSPECTIVES

The high prevalence of cognitive impairment [13] and affective disorders in PwPD [14] has a great impact on quality of life and caregiver burden [15]. Pharmacotherapy often has only a limited effect for these symptoms, while it may be associated with adverse effects on cognition or alertness. Therefore, it is encouraging to see that non-pharmacological interventions are receiving much more attention to alleviate these non-motor symptoms, in the hope that these may play a pivotal role in their future treatment. While there is no doubt that physical exercise improves physical outcomes in PwPD [6], its impact on brain health is manifold and may also beneficially affect mental health problems, including cognition and affect [16, 17]. These multifaceted effects of exercise are considered extensively in this issue. Also, to treat affective disorders further, next to cognitive behavioral therapy, which is well-known to be effective yet rarely prescribed for PwPD, novel experimental interventions are being discussed, including non-invasive brain stimulation, electroconvulsive therapy, light therapy, and art interventions. As demonstrated in this issue, much research is needed to fully understand the mechanisms and the potential of these interventions for treating mental symptoms and to promote mental health in PwPD. What should be kept in mind is that many of these treatments could be delivered digitally. While digital health technology for PwPD is developing rapidly [18] (e.g. in the context of telehealth, deep brain stimulation, wearable sensors, and smartphone applications), health literacy may be lagging behind, yet is indispensable for adherence. This said, the insufficiency in digital skills as well as the inequities in access to digital health technologies in certain populations still constitute a major challenge for PwPD to benefit from this therapeutic avenue. Therefore, it will not only be important to develop and optimize new technologies, but also ways to enhance digital health literacy in PwPD regardless of their background. Only if patients are empowered and learn self-management strategies that are tailored to their specific wishes and needs will they be able to play a key role as managers of their disease to improve their care and quality of life. Concepts to achieve this important role are also reviewed in this issue.

PERSPECTIVES ON ACCESS

Access to patient-centered care is a key issue for PwPD, not only requiring sufficient allied health resources but also a different way of thinking about the organization of care management [19]. This section addresses several facets of the diversity of access to adequate multidisciplinary expertise, as well as a balanced view on its benefits and drawbacks. As the communication between expert team members is vital for the success of integrated care models, it is espoused that the Parkinson nurse specialist is ideally placed for care titration, referral to allied health professionals, and fulfillment of many other roles in the holistic care of PwPD.

Obtaining mere access to allied health professionals can be surprisingly disappointing even in developed countries [20]. However, the current challenges faced by the African continent afford a special consideration in this issue. A possible solution is offered by enhancing remote access through the development of telehealth platforms, thereby avoiding expensive travelling in underserved areas. Remote allied health platforms have grown spectacularly in the last five years, now covering speech therapy, exercise interventions, occupational therapy, and multidisciplinary management. While online-management reduces healthcare cost, a more thorough understanding of the pros and cons of remote service delivery is warranted and also tackled in this issue.

CONCLUSION

In conclusion, it is gratifying to witness that non-pharmacological interventions are subject to critical thinking, continuous updating of knowledge, and scientific scrutiny. As editors of this special issue, we are happy to present this exciting work, while concluding that the field of non-pharmacological therapy is clearly reaching clinical and scientific maturity and has the potential to substantially improve patient care in the future.