This is the current release of the guideline.

Parkinson disease

Management
Treatment

Family Practice
Geriatrics
Internal Medicine
Neurology

Physicians

To define key issues in the management of Parkinson disease (PD) relating to neuroprotective strategies and alternative treatments, and to make evidence-based treatment recommendations

Patients with Parkinson disease

Treatment/Management

1. Levodopa
2. Exercise therapy
3. Speech therapy

Interventions and practices considered but not recommended include vitamin E, riluzole, coenzyme Q10, pramipexole, ropinirole, rasagiline, amantadine, thalamotomy, selegiline, Mucuna pruriens, acupuncture, manual therapy, biofeedback, and Alexander technique.

• Rate of disease progression
• Motor function
• Speech volume
• Neuroprotective effect

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

For the literature review, the following databases were searched: MEDLINE, EMBASE, CINHAL, and Cochrane Database of Systematic Reviews for the years 1997–2002. Only articles written in English were included. A second MEDLINE search covered 1966–August 2004, followed by a secondary search using the bibliographies of retrieved articles and knowledge from the expert panel extending to January 2005.

Results, Key Words, and Inclusion/Exclusion Criteria

For question 1 (Are there any therapies that can slow the progression of Parkinson disease [PD]?):

• Search terms: Parkinson disease, disease progression, antiparkinson agents, monoamine oxidase inhibitors, levodopa, amantadine, dopamine agonists, ascorbic acid, vitamin E, and coenzyme Q.
• Inclusion criteria: Studies of rates of disease progression in patients with early PD using potential neuroprotective agents. Articles dealing only with symptomatic benefit were excluded. At least 6 months of follow-up were required. Articles discussing selegiline were reviewed in a previous Practice Parameter.
• Categories found: amantadine, coenzyme Q10, levodopa, pramipexole (with and without imaging), rasagiline, ropinirole (with imaging), thalamotomy, vitamin C, vitamin E.

For question 2 (Are there any nonstandard pharmacologic or nonpharmacologic therapies that have been shown to improve motor function in PD?):

• Search terms: Parkinson disease, rehabilitation, complementary therapies, medicinal plants, vitamins, dietary supplements, homeopathy, holistic health, acupuncture, chiropractice, manipulation, physiotherapy, speech therapy, and tai chi.
• Inclusion criteria: At least 10 subjects included in study with treatment of at least 1 week duration.
• Categories found: naturopathic treatments, physiotherapy, speech therapy, vitamin therapy (folic acid, pyridoxine, ascorbic acid, vitamin E, vitamin D, vitamin K 2), chiropractice, acupuncture, Alexander technique, music therapy, osteopathic manipulation.

For question 1 (Are there any therapies that can slow the progression of Parkinson disease?): 11 articles satisfied inclusion criteria.

For question 2. (Are there any nonstandard pharmacologic or nonpharmacologic therapies that have been shown to improve motor function in Parkinson disease [PD]?): 22 articles satisfied inclusion criteria.

Weighting According to a Rating Scheme (Scheme Given)

Classification of Evidence for Therapeutic Articles

Class I: Prospective, randomized, controlled clinical trial with masked outcome assessment, in a representative population. The following are required:

1. primary outcome(s) is/are clearly defined
2. exclusion/inclusion criteria are clearly defined
3. adequate accounting for drop-outs and cross-overs with numbers sufficiently low to have minimal potential for bias
4. relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences

Class II: Prospective matched group cohort study in a representative population with masked outcome assessment that meets a-d above OR a randomized control trial (RCT) in a representative population that lacks one criterion a-d

Class III: All other controlled trials including well-defined natural history controls or patients serving as own controls in a representative population, where outcome assessment is independently assessed or independently derived by objective outcome measurement*

Class IV: Evidence from uncontrolled studies, case series, case reports, or expert opinion

* Objective outcome measurement: an outcome measure that is unlikely to be affected by an observer's (patient, treating physician, investigator) expectation or bias (e.g., blood tests, administrative outcome data)

Systematic Review with Evidence Tables

The majority of articles were reviewed by the full panel. If a panelist was an author of one of the articles, at least two other panelists reviewed that article. If a disagreement was identified, consensus was reached by discussion with the whole group. The risk of bias for each study was determined using the classification of evidence scheme.

Other

Not stated

Classification of Recommendations

Level A = Established as effective, ineffective, or harmful for the given condition in the specified population. (Level A rating requires at least two consistent Class I studies.)

Level B = Probably effective, ineffective, or harmful for the given condition in the specified population. (Level B rating requires at least one Class I study or at least two consistent Class II studies.)

Level C = Possibly effective, ineffective, or harmful for the given condition in the specified population. (Level C rating requires at least one Class II study or two consistent Class III studies.)

Level U = Data inadequate or conflicting; given current knowledge, treatment is unproven.

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Draft guidelines were reviewed for accuracy, quality, and thoroughness by the American Academy of Neurology members, topic experts, and pertinent physician organizations.

Final guidelines were approved by the American Academy of Neurology Quality Standards Subcommittee on July 30, 2005, the American Academy of Neurology Practice Committee on December 15, 2005, the American Academy of Neurology Board of Directors on February 23, 2006. They were published in Neurology 2006;66:975-982.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate use of neuroprotective strategies and alternative therapies in patients with Parkinson disease (PD) leading to improvements in motor function and speech volume

Not stated

This statement is provided as an educational service of the American Academy of Neurology (AAN). It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use a specific procedure. Neither is it intended to exclude any reasonable alternative methodologies. The AAN recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all of the circumstances involved.

An implementation strategy was not provided.

Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

2006 Apr 11

American Academy of Neurology - Medical Specialty Society

American Academy of Neurology (AAN)
Michael J. Fox Foundation

Quality Standards Subcommittee

Primary Authors: O. Suchowersky, MD; G. Gronseth, MD; J. Perlmutter, MD; S. Reich, MD; T. Zesiewicz, MD; W.J. Weiner, MD

Quality Standards Subcommittee Members: Gary Gronseth, MD (Co-Chair); Jacqueline French, MD (Co-Chair); Charles E. Argoff, MD; Stephen Ashwal, MD (ex-officio); Christopher Bever, Jr., MD; John D. England, MD; Gary Franklin, MD, MPH (ex-officio); Gary H. Friday, MD; Larry B. Goldstein, MD; Deborah Hirtz, MD (ex-officio); Robert G. Holloway, MD, MPH; Donald J. Iverson, MD; Leslie Morrison, MD; Clifford J. Schostal, MD; David J. Thurman, MD, MPH; Samuel Wiebe, MD; William J. Weiner, MD (facilitator)

Dr. Suchowersky has received consulting fees from Teva, speaker fees from GlaxoSmithKline, and research funds from Boehringer Ingelheim, Kyowa, Merck, Amarin, Cephalon, Swartz-Pharma, and Solstice Neuroscience. Dr. Reich has received research funds from Guilford Pharmaceuticals and Cephalon. Dr. Perlmutter has received unrestricted educational funds from Medtronic. Dr. Zesiewicz has received consulting fees from UCB Pharma and Schwartz Pharma, speaker fees from Boehringer Ingelheim, GlaxoSmithKline, Novartis and Medtronic, and research funds from Boehringer Ingelheim, GlaxoSmithKline, Novartis and Merck. Dr. Weiner is a consultant for Teva, a speaker for Boehringer Ingelheim, and has received research funds from Boehringer Ingelheim and Teva. Dr. Gronseth has nothing to disclose.

National Parkinson Foundation - Disease Specific Society
Parkinson's Disease Foundation - Disease Specific Society

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on June 6, 2006. The information was verified by the guideline developer on September 26, 2006.

This NGC summary is based on the original guideline, which is copyrighted by the American Academy of Neurology.