Original article

Effects of 3­4 Weeks of Multimodal Complex Treatment for
Parkinson’s Disease on Motor Function and Quality of Life:A Retrospective Study
Masaki Iwamura1, 2*, Yusuke Okamoto2, Yuko Oshio2, Akiko Nakano3, Taro Shigekiyo4, Kazushi Yamane4,
Masakazu Sugino4
1

Department of Physical Therapy, Faculty of Health Science, Aino University
Department of Rehabilitation, Aino Hospital3
Department of Clinical Psychology, Aino Hospital
4
Department of Neurology, Aino Hospital
2Abstract
Purpose : The effectiveness of multimodal complex treatment for
Parkinson’s disease (PD-MCT) has recently attracted attention. However,there are differences in the PD-MCT content across institutions. Therefore,
we aimed to elucidate the effectiveness of PD-MCT at our hospital andcontribute to determining the optimal intensity and duration of theintervention.
Methods: This retrospective study enrolled 144 inpatients who underwent
PD-MCT at our hospital between March 2015 and June 2023. The primary
endpoints were the Movement Disorder Society-Unified Parkinson’s Disease
Rating Scale part III (MDS-UPDRS part III) before and after admission toassess motor function, and the Parkinson’s Disease Questionnaire-39
summary index (PDQ-39 SI) before admission and 1 month after discharge toassess quality of life. The PD-MCT at our hospital was conducted during a 34-weeks hospital stay, with approximately 12 h of rehabilitation per week.
After selecting participants with no missing data, 58 were selected for theMDS-UPDRS part III comparison, and eight were selected for the PDQ-39
comparison. The analysis was conducted using a paired t-test for normally
distributed data and a Wilcoxon signed-rank sum test for non-normally
distributed data, with a significance level of 5%.
Results: The total score of MDS-UPDRS part III was 34.7± 13.3 before
admission and 28.6±12.3 at discharge, and the PDQ-39 SI was 34.0±13.5
before admission and 23.9±9.9 1 month after discharge, showing significantimprovement (p＜0.01 and p＜0.05, respectively).
Conclusion: Motor function and quality of life significantly improved in thisstudy. In particular, the improvement in the quality of life was sustainedeven 1 month after discharge. However, the study was retrospective, andmany participants were excluded during the selection process, which may
have caused a selection bias.

Submitted Sep. 30. 2023
Accepted Jan. 19. 2024
*Correspondence
Masaki Iwamura
Department of Physical Therapy,
Faculty of Health Science,
Aino University
E-mail:m-iwamura@pt-u.aino.ac.jp
Keywords
Parkinson’s disease
Multimodal complex treatment
Quality of life

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Introduction
Parkinson’s disease (PD) is a progressive condition that
affects both mental and motor functions due to decreased
dopamine secretion resulting from the degeneration of thesubstantia nigra1) . Treatment is centered on pharmacotherapy, but non-pharmacological interventions, such as
rehabilitation and psychological care, also play a majorrole in maintaining and improving the psychomotor
functions of patients2) . In addition, as PD is progressive,
patients’ active participation in their treatment, such as
understanding the disease and participating in various
activities, significantly influences treatment effectiveness.
Because of the importance of multimodal complex
treatment for patients with PD, a multimodal complex
treatment concept for PD ( PD-MCT ) has been
implemented in Germany by a multimodal complex teamincluding physicians, pharmacists, dietitians, nurses, careworkers, clinical psychologists, physical therapists, occupational therapists, speech therapists, and care supportspecialists3).
Despite numerous reports on the effectiveness of PDMCT in recent years, there is a lack of uniformity inthese findings. The efficacy of PD-MCT varies greatly not
only from country to country but also among providers inthe same country4) . In addition, the importance of using
subjective evaluation scales as indices of the effectivenessof interventions for patients with PD has attracted
attention in recent years, especially for the evaluation ofquality of life (QOL)5) . A systematic review6) comparing
the QOL of patients with PD with that of healthy
participants found that the QOL of patients with PD wassignificantly lower than that of healthy participants,
particularly in terms of motor function. Therefore,improving QOL in terms of motor function is an important
aspect of therapeutic interventions for patients with PD. It
is imperative to urgently clarify the effective intervention
period and intensity for improving QOL with PD-MCT.
The duration of hospitalization and the hours ofrehabilitation per week ( duration / intensity ) of PD-MCT
performed at our hospital consisted of 3-4 weeks / 12 h,
and the duration of hospitalization and intervention
intensity were between 4 weeks/21 h7) and 2 weeks/7.5h8).
This study aimed to examine changes brought about by
PD-MCT in the Movement Disorder Society Unified
Parkinson’s Disease Scale part III (MDS-UPDRS part III),a comprehensive evaluation scale for PD, and theParkinson’s Disease Questionnaire-39 (PDQ-39), a QOL
scale specifically designed for patients with PD todetermine the duration and intensity of intervention in PD-MCT.

Methods
Study design
This was a retrospective cohort study.

Participants
The participants included 144 patients who underwent
PD-MCT ( first session only ) at our hospital between
March 2015 and June 2023. Exclusion criteria were adiagnosis other than PD, severe mental or medical
problems that prevented therapeutic intervention, andmissing data in the collected data. This study wasapproved by the Ethics Committee of Aino Hospital.

Data collection
Basic information such as height, weight, sex, age,duration of PD, number of days hospitalized, Hoehn &Yahr ( H-Y ) classification at admission, hours ofrehabilitation during the week, levodopa equivalent daily
dose ( LEDD ) and the Mini Mental State Examination(MMSE) score at admission, Geriatric Depression Scale
30 ( GDS-30 ) score at admission, MDS-UPDRS part III
score at admission and discharge, and PDQ-39 atadmission and within 30 ± 7 days after discharge werecollected from the medical records.

Implementation procedure
First, the history of PD-MCT was retrieved from thepatients’ medical records, and only patients who were first-time PD-MCT users were selected. Next, patientsdiagnosed with PD who had no deterioration of theirgeneral condition or refused to participate in the program
during hospitalization were selected, and basic informationon these patients was collected. The dataset wasconstructed from patients with no deficits in the MMSE,
GDS-30, MDS-UPDRS part III, or PDQ-39 on admission.
The first analysis included patients who completed theMDS-UPDRS part III at discharge, and the second
analysis included patients who were assessed with thePDQ-39 within 30±7 days after discharge.

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Multimodal complex treatment
Team members included physicians, nurses, pharmacists, physical therapists, occupational therapists, speechtherapists, clinical psychologists, dietitians, and socialworkers. The program included rehabilitation performedby rehabilitation specialists, medication counseling bypharmacists, dietary guidance by dietitians, and psychological counseling by clinical psychologists, with conferences held in the 1 st and 3 rd weeks to share
information and determine future plans. Other programs
include tea conversation meetings once or twice perhospitalization, a singing group ( voluntary participation )once a week, Aino’s Parkinson’s danceⓇ (about 30 min)twice a week, and tactile care once a week (Table 1).
Our PD-MCT encourages patient interaction throughtea conversation meetings and Aino’s Parkinson’s danceⓇ .
Aino’s Parkinson’s danceⓇ is a seated-based program
consisting of “warm-up,” “upper limb movement,” “lowerlimb movement, ” “ center of gravity shift, ” and “ cooldown.” The dance arrangement was created by physicaland occupational therapists at the hospital, incorporating a“ combination of simple movements, ” “ repetition, ” and“concrete visualization of movements.”

Outcome
The primary outcome was the total score of the MDSUPDRS part III, and the scores of the questionnaire items
were classified into four subscales: rigidity (No.3), tremor(No.15, 16, 17, and 18), bradykinesia (No.2, 4, 5, 6, 7, 8,and 14), and axial symptoms (No.1, 9, 10, 11, 12, and 13).
The secondary outcome was the PDQ-39, which
consists of 39 questions ( 156 points ) in eight domains(mobility, activities of daily living, emotional well-being,
stigma, social support, cognition, communication, andbodily discomfort)9).
In this study, the PDQ-39 Summary Index ( PDQ-39SI)9) , which standardizes the total score to a 100-point
scale and the total score for each of the eight domains,
was used. The PDQ-39 was completed by the patientsthemselves, and the MDS-UPDRS Part III was evaluatedby therapists trained in the evaluation method.

Statistics
The MDS-UPDRS part III items (total, rigidity, tremor,
bradykinesia, and axial symptoms) and PDQ-39 items (SI,mobility, activities of daily living, emotional well-being,stigma, social support, cognition, communication, andbodily discomfort) were compared before and after the PD-MCT.
For each value, normality was determined using theShapiro-Wilk test. The paired t-test was used for normally
distributed data, Wilcoxon signed-rank sum test for nonnormally distributed data, and McNemar’s test for nominal
scales. For each effect size, Cohen’s d was calculated forthe paired t-test, and r was calculated by dividing thestatistical test quantity converted to Z by √ N for theWilcoxon signed rank sum test. SPSS statistics version 2
was used for all statistical analyses, with a significance

Table 1. One-week program of PD-MCT

OT, occupational therapy; ST, speech therapy; PT, physical therapy

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level of 5%.

Results
Fifty-eight participants were included in the first
analysis, and eight were included in the second analysis(Figure 1). The participants’ characteristics (first/second
measurement points) were as follows: duration of disease,7.1±5.8/6.9±5.5 years; hospitalization, 24.9±4.2/22.9±3.8 days; rehabilitation time per week, 11.6±1.3/12.1±0.7h; and LEDD 505±246 mg/430±159 mg per week. The
number of women and Hoehn and Yahr stages 3, and 4
were significantly different (Table 2). The changes in theMDS-UPDRS part III before and after the PD-MCT
showed significant improvements in all items (Table 3),
and the changes in the PDQ-39 showed significant
improvements in the dimensions of PDQ-39 SI, mobility,
activities of daily living, and bodily discomfort (Table 4).

Discussion
In this study, we retrospectively investigated theeffectiveness of PD-MCT ( 3-4 weeks, 12 h / week )performed at our hospital to determine the appropriate
length of hospitalization and rehabilitation hours for PDMCT.
The MDS-UPDRS part III change in this study was−6.1 points, which was higher than the minimal clinicallyimportant difference (MCID) of −3.25 points9). It was also
comparable to the −4.8 score reported by Scherbaum etal.8) ( 2 weeks / 7.5 h ) , who conducted a PD-MCT
intervention similar to that in the present study. The
comparison of changes in the MDS-UPDRS part III
showed significant improvements in all sub-items including rigidity, tremor, bradykinesia, and axial symptoms,
with particularly high effect sizes for bradykinesia andaxial symptoms. In our PD-MCT rehabilitation program,
we used muscle-strengthening and balance-strengthening
exercises to address the individual physical function
problems of patients. In previous studies, such rehabilitation programs were effective in treating drug-resistantaxial symptoms, and PD-MCT in the present study wasFigure 1. Participant recruitment chart
PD syndrome, Parkinson’s disease syndrome; PSP, progressive supranuclear palsy; MSA, multiple system
atrophy ; PD-MCT, Parkinson’s disease - Multimodal complex treatment ; MMSE, Mini-Mental State
Examination; GDS 30, Geriatric Depression Scale 30; MDS-UPDRS part III, Movement Disorder Society
Unified Parkinson’s Disease Scale part III; PDQ-39, Parkinson’s Disease Questionnaire-39

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Table 2. Participants’ basic information

Nominal variable, n (%); continuous variable, mean±SD; MMSE, Mini-Mental State Examination; GDS 30,Geriatric Depression Scale 30; LEDD, levodopa equivalent daily dose
Table 3. Comparison of MDS-UPDRS part III pre and post PD-MCT

Nominal variable, n (%); continuous variable, mean±SD; LEDD, levodopa equivalent daily dose

Table 4. Comparison of PDQ-39 pre and post PD-MCT

Nominal variable, n (%); continuous variable, mean±SD; LEDD, levodopa equivalent daily dose

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considered effective in improving these symptoms.
The MCID of the PDQ-39 SI was reported at − 1.6points10) , whereas the change in the present study was− 10.2 points approximately 4 weeks after discharge,
indicating sufficient improvement. Scherbaum et al. ( 2weeks/7.5 h)8) reported that the effect was not maintained
after 6 weeks. Mullar et al.11) reported that PD-MCT washighly effective during a hospitalization period ofapproximately 21 days. In the present study, sufficient
improvement was observed as measured with the MDSUPDRS part III, and a sustained effect was demonstrated
with the PDQ-39. This sustained effect, not observed in
the 2-week intervention, suggests that 3 weeks or longer
may be preferable as an effective period for PD-MCT interms of a sustained effect on QOL. Marumoto et al.12)
compared the effects of a rehabilitation professionalcentered intervention (Medical Rehabilitation: MR) and anintervention involving various means such as dance,music therapy, and other education and guidance(enhanced multidisciplinary care: EMC) and reported that
the EMC group showed significantly improved QOL, axialsymptoms, and non-motor symptoms compared to the MRgroup. In addition to rehabilitation, our PD-MCT program
also includes tea conversation meetings, a singing group,and Aino’s Parkinson’s danceⓇ . Various other activities
are conducted in addition to rehabilitation, and it ispossible that the effects of these interventions may beapparent.
The PDQ-39 sub-items showed significant improvement, especially those related to physical function such as
mobility ( Cohen’s d ＝ 1.14 ) , activities of daily living(Cohen’s d＝0.86), and bodily discomfort ( Cohen’s d ＝1.16). In contrast, Ferrazzoli et al.7) , whose study had asimilar length of hospitalization to that of the present
study, reported significant improvements in all items
except stigma, which may have been influenced bydifferences in intervention intensity (12 h in the present
study and 21 h in the study of Ferrazzoli et al.7).
Based on the above, it is assumed that a length ofhospitalization of 3 weeks or longer is preferable for PDMCT. However, if a higher intervention intensity iseffective in improving QOL, a length of hospitalization of
3 weeks or less may be sufficient. In addition tointerventions by rehabilitation professionals, it has
become clear that the involvement of multiple professions
improves QOL ; therefore, it is important to build anorganization that allows the organic involvement ofmultiple professions. Recommendations for theorganization of PD-MCT were proposed by Danique etal.13) in 2020, and the accumulation of knowledge andinformation sharing regarding the organization of PD-MCT
based on these recommendations will be an issue for thefuture. Complications in the introduction of PD-MCT
include the complexity of the paperwork and the need forcontinued human resource development. The staff isburdened with sharing PD-MCT information, holding
conferences, and training personnel to provide highquality treatment in addition to their busy normalschedule.
A limitation is this study is its retrospective nature, andthere is a high possibility of selection bias in the results
owing to the large number of dropouts. In other words, it
is possible that participants who showed high adherence
were easier to follow up, and as a result, participants who
were more likely to maintain the effect of QOL
improvement may have remained. In addition, it isdifficult to verify the effectiveness of individual efforts
because the PD-MCT is the result of an intervention
involving various occupations.

Conclusion
The effectiveness of our PD-MCT (3-4 weeks/12 h) wasverified, and a certain level of improvement in motor
function and QOL was achieved. Further studies arerequired to determine whether shorter periods of PDMCT are effective.

Conflict of Interest
The authors have no conflict of interest to declare.

Acknowledgments
We appreciate the cooperation of patients and theirfamilies in this study. We also take this opportunity tothank the staff of PD-MCT for their cooperation in theorganization and management of PD-MCT.

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