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Guideline

Canadian guideline for Parkinson disease

David Grimes, Megan Fitzpatrick, Joyce Gordon, Janis Miyasaki, Edward A. Fon, Michael Schlossmacher, Oksana Suchowersky, Alexander Rajput, Anne Louise Lafontaine, Tiago Mestre, Silke Appel-Cresswell, Suneil K. Kalia, Kerrie Schoffer, Mateusz Zurowski, Ronald B. Postuma, Sean Udow, Susan Fox, Pauline Barbeau and Brian Hutton
CMAJ September 09, 2019 191 (36) E989-E1004; DOI: https://doi.org/10.1503/cmaj.181504
David Grimes
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Megan Fitzpatrick
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Joyce Gordon
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Janis Miyasaki
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Edward A. Fon
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Michael Schlossmacher
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Oksana Suchowersky
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Alexander Rajput
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Anne Louise Lafontaine
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Tiago Mestre
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Silke Appel-Cresswell
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Suneil K. Kalia
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Kerrie Schoffer
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Mateusz Zurowski
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Ronald B. Postuma
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Sean Udow
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Susan Fox
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Pauline Barbeau
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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Brian Hutton
The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute (Grimes, Fitzpatrick, Schlossmacher, Mestre), Ottawa, Ont.; Parkinson Canada (Gordon), Toronto, Ont.; University of Alberta Hospital (Miyasaki), Edmonton, Alta.; Montreal Neurological Institute (Fon), McGill University, Montréal, Que.; University of Alberta (Suchowersky), Edmonton, Alta.; Royal University Hospital (Rajput), University of Saskatchewan, Saskatoon, Sask.; Montreal General Hospital (Lafontaine, Postuma), McGill University, Montréal, Que.; Pacific Parkinson’s Research Centre, Djavad Mowafaghian Centre for Brain Health (Appel-Cresswell), University of British Columbia, Vancouver, BC; Toronto Western Hospital (Kalia, Zurowski, Fox), University of Toronto, Toronto, Ont.; Dalhousie University (Schoffer), Halifax, NS; University of Manitoba Rady Faculty of Health Sciences (Udow), Winnipeg, Man.; Knowledge Synthesis Group (Barbeau, Hutton), Ottawa Hospital Research Institute, Ottawa, Ont.
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  • Some comments and suggestions re the presentation of Canadian Guidelines for Parkinson Disease
    Joanabbey Sack
    Posted on: 20 December 2019
  • Re: Canadian Guideline for Parkinson Disease - clarification on Palliative Care & MAiD
    Leonie Herx MD PhD CCFP (PC) FCFP
    Posted on: 17 October 2019
  • Posted on: (20 December 2019)
    Page navigation anchor for Some comments and suggestions re the presentation of Canadian Guidelines for Parkinson Disease
    Some comments and suggestions re the presentation of Canadian Guidelines for Parkinson Disease
    • Joanabbey Sack, Educator, Dance Movement Therapist Drama Therapist, Concordia University /Parkinson en Mouvement

    Date: December 16, 2019
    Dear Editor,
    Thank you for the making available the Canadian Guideline for Parkinson Disease (CMAJ, Oct 19) with its extensive documentation of expertise and ethical rigor. For the past 12 years, since co-founding Parkinson en mouvement, I and my colleagues have built up years of observation in our work with Parkinson patients using various movement-based therapies.

    1. We were surprised to read as one of the key points that new therapies such as deep brain stimulation and intrajejunal levodopa-carbidopa gel infusion are now “routinely” used in Parkinson disease to manage motor symptoms (pages E989 and E1001). Our impression is that these very expensive treatments are as yet far from “routine”. They appear to be available to a highly selected category of patients, at high cost, with the need for specialized technical follow-up for the rest of their lives. There are also myriad potential side effects to these new treatments.

    2. On the other hand, we strongly agree when the Guideline asserts - as another key point - that evidence exists to support early institution of exercise at the time of diagnosis, in addition to the clear benefit in those with well-established disease. However, under the Treatment section of the Guideline, we would have added additional movement-based therapies for which there is solid research evidence in addition to the two referenced of physiotherapy and occupation therapy.(1-14) Moreover, there is...

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    Date: December 16, 2019
    Dear Editor,
    Thank you for the making available the Canadian Guideline for Parkinson Disease (CMAJ, Oct 19) with its extensive documentation of expertise and ethical rigor. For the past 12 years, since co-founding Parkinson en mouvement, I and my colleagues have built up years of observation in our work with Parkinson patients using various movement-based therapies.

    1. We were surprised to read as one of the key points that new therapies such as deep brain stimulation and intrajejunal levodopa-carbidopa gel infusion are now “routinely” used in Parkinson disease to manage motor symptoms (pages E989 and E1001). Our impression is that these very expensive treatments are as yet far from “routine”. They appear to be available to a highly selected category of patients, at high cost, with the need for specialized technical follow-up for the rest of their lives. There are also myriad potential side effects to these new treatments.

    2. On the other hand, we strongly agree when the Guideline asserts - as another key point - that evidence exists to support early institution of exercise at the time of diagnosis, in addition to the clear benefit in those with well-established disease. However, under the Treatment section of the Guideline, we would have added additional movement-based therapies for which there is solid research evidence in addition to the two referenced of physiotherapy and occupation therapy.(1-14) Moreover, there is a group dimension to the treatments we and others offer which can mitigate isolation and loneliness which no doubt contribute to the risk of apathy as a barrier to patient adherence mentioned on page E1001 (“Continued therapy is required to sustain benefits, and this is particularly important in Parkinson disease as apathy is a barrier to patient adherence in the absence of scheduled lessons or training”).

    3. Given the concern expressed in the Guideline about the current state of limited resources for Parkinson care, the Rehabilitation section could have been strengthened. As it now appears in the Guideline, this section is practically lost in the 2.5 pages of detailed accounting of the evidence for various pharmacological options. Because a range of movement-based therapies (physio exercises, dance, dance movement therapy, LSVT Big and Loud, etc.) are widely available at low cost, with few side effects, it would make sense to highlight more clearly the recommendation of these interventions as one of the first lines of treatment.

    4. On the visual summaries (page E991) can be seen as quite misleading and potentially discouraging to the target audience. If read alone they focus on negative and often misunderstood aspects of Parkinson’s. The ending statement that ‘No therapies are effective for slowing or stopping brain degeneration in Parkinson disease’ may leave readers with a sense of hopelessness. I question this statement having such a prominent place. The image of a dark and rounded silhouette is complimented by the headline of palliative care, a stethoscope and even the one image of a person in exercise or stretch has a pill sharing the image box.

    5. The panel of experts taking part in the discussions and development of guidelines is impressive. But, it would be valuable to include non-medical practitioners, movement-based therapists and representatives of the patient population itself. In our classes of movement and dance there are physicians, psychologists, educators, lawyers, performers and others. These people could have been called upon to testify in their role of professionals and people living with Parkinson’s to contribute to the development of these guidelines.

    Thank you again for this important collaborative update on PD.

    Joanabbey Sack

    References

    1. Batson, G., Migliarese, S. J., Soriano, C., H. Burdette, J., & Laurienti, P. J. (2014). Effects of Improvisational Dance on Balance in Parkinson's Disease: A Two-Phase fMRI Case Study. Physical & Occupational Therapy In Geriatrics, 32(3), 188-197. doi:10.3109/02703181.2014.927946

    2. Batson G. (2010) Feasibility of an intensive trial of modern dance for adults with Parkinson disease. Complementary Health Practice Review15: 65. doi: 10.1177/1533210110383903

    3. Chaudhary, S., Joshi, D., Pathak, A., Mishra, V. N., Chaurasia, R. N., & Gupta, G. (2018). Comparison of Cognitive Profile in Young- and Late-onset Parkinson's Disease Patients. Ann Indian Acad Neurol, 21(2), 130-132. doi:10.4103/aian.AIAN_262_17

    4. Duncan, R. P., & Earhart, G. M. (2012). Randomized controlled trial of community-based dancing to modify disease progression in Parkinson's disease. Neurorehabilitation and Neural Repair, 26 (2), 132-143.

    5. Earhart, G. M. (2009). Dance as therapy for individuals with Parkinson disease. Eur J Phys Rehabil Med, 45(2), 231-238. Earhart, G. M. (2009). Dance as therapy for individuals withParkinson's disease. European Journal of Physical and Rehabilitation Medicine, 45(2), 231-238.

    6. Farley, B. G., Fox, C. M., Ramig, L. O., & McFarland, D. (2008). Intensive amplitude-specific therapeutic approaches for Parkinson disease: Toward a neuroplasticity-principled rehabilitation model. Topics in Geriatric Rehabilitation, 24(2), 99-114. doi:10.1097/01.tgr.0000318898.87690.0d

    7. Foster, E. R., Golden, L., 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. Arch Phys Med Rehabil, 94(2), 240-249. doi:10.1016/j.apmr.2012.07.028

    8. Goodwin, V. A., Richards, S. H., Taylor, R. S., Taylor, A. H., & Campbell, J. L. (2008). The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis. Mov Disord, 23(5), 631-640. doi:10.1002/mds.21922

    9. Hackney, M. E., & Earhart, G. M. (2009). Effects of dance on movement control in Parkinson's disease: a comparison of Argentine tango and American ballroom. J Rehabil Med, 41(6), 475-481. doi:10.2340/16501977-0362

    10. Homann, K. B. (2010). Embodied Concepts of Neurobiology in Dance/Movement Therapy Practice. American Journal of Dance Therapy, 32(2), 80-99. doi:10.1007/s10465-010-9099-6

    11. Kalyani, H. H. N., Sullivan, K. A., Moyle, G., Brauer, S., Jeffrey, E. R., & Kerr, G. K. (2019). Impacts of dance on cognition, psychological symptoms and quality of life in Parkinson's disease. NeuroRehabilitation, 45(2), 273-283. doi:10.3233/nre-192788

    12. Mendrek A. (2019) From depression to Parkinson's disease: The healing power of dance the conversation.com › from-depression-to-parkinsons-disease-the-healing-... Dec 4, 2019 https://theconversation.com/from-depression-to-parkinsons-disease-the-he...

    13. Prewitt, C. M., Charpentier, J. C., Brosky, J. A., & Urbscheit, N. L. (2017). Effects of Dance Classes on Cognition, Depression, and Self-Efficacy in Parkinson’s Disease. American Journal of Dance Therapy, 39(1), 126-141. doi:10.1007/s10465-017-9242-8

    14. Stevens, C., & McKechnie, S. (2005). Thinking in action: thought made visible in contemporary dance. Cogn Process, 6(4), 243-252.

    Show Less
    Competing Interests: None declared.
  • Posted on: (17 October 2019)
    Page navigation anchor for Re: Canadian Guideline for Parkinson Disease - clarification on Palliative Care & MAiD
    Re: Canadian Guideline for Parkinson Disease - clarification on Palliative Care & MAiD
    • Leonie Herx MD PhD CCFP (PC) FCFP, President, Canadian Society of Palliative Care Physicians

    The Canadian Society of Palliative Care Physicians (CSPCP) welcomes the inclusion of palliative care in the new Canadian Guideline for Parkinson Disease (1) and commends the authors for making it one of their five key recommendations. Early integration of a palliative approach to care is essential for all persons with serious and life-threatening illnesses, including those with neurological illnesses (2-3).

    However the CSPCP strongly disagrees with the way that Medical Assistance in Dying (MAiD) is portrayed throughout the Guideline as being an option included under palliative care. Palliative care and MAiD are distinct, as recognized in Canadian Medical Association (CMA) General Council Resolution GC 15-35, which states that: “Assisted death as defined by the Supreme Court of Canada is distinct from the practice of palliative care”.

    National and international standards for palliative care, including the World Health Organization’s definition of palliative care, clearly state that palliative care focuses on providing support to enable people to live as well as possible until they die but “does not hasten death” (4). MAiD is a legal option for some patients who qualify and choose to pursue it but is not part of a palliative approach, as described in our CSPCP Key Messages on Palliative Care and MAiD (5).

    Confusion ensues when MAiD is seen as part of palliative care. Linking MAiD and palliative care perpetuates the myth that palliative care hastens dea...

    Show More

    The Canadian Society of Palliative Care Physicians (CSPCP) welcomes the inclusion of palliative care in the new Canadian Guideline for Parkinson Disease (1) and commends the authors for making it one of their five key recommendations. Early integration of a palliative approach to care is essential for all persons with serious and life-threatening illnesses, including those with neurological illnesses (2-3).

    However the CSPCP strongly disagrees with the way that Medical Assistance in Dying (MAiD) is portrayed throughout the Guideline as being an option included under palliative care. Palliative care and MAiD are distinct, as recognized in Canadian Medical Association (CMA) General Council Resolution GC 15-35, which states that: “Assisted death as defined by the Supreme Court of Canada is distinct from the practice of palliative care”.

    National and international standards for palliative care, including the World Health Organization’s definition of palliative care, clearly state that palliative care focuses on providing support to enable people to live as well as possible until they die but “does not hasten death” (4). MAiD is a legal option for some patients who qualify and choose to pursue it but is not part of a palliative approach, as described in our CSPCP Key Messages on Palliative Care and MAiD (5).

    Confusion ensues when MAiD is seen as part of palliative care. Linking MAiD and palliative care perpetuates the myth that palliative care hastens death and may prevent patients from seeking early palliative care interventions, which improve quality of life and in some cases even enable people to live longer. The Canadian public must be able to continue to trust that the principles of palliative care remain focused on effective symptom management and psychological, social, and spiritual interventions to help people live as well as they can until their death.

    The CSPCP recommends that the authors clarify the important distinction between palliative care and MAiD in their Guideline. In particular, we recommend that the visual summary of recommendations (p.41) be modified to include a sixth coloured box which would list MAiD as a separate option from palliative care, so the two are not conflated.

    The CSPCP advocates for universal access to high quality palliative care to address the suffering experienced by patients with Parkinson Disease and their families. The distinction between palliative care and MAiD must be clearly articulated and understood.

    References:
    1. CMAJ 2019 September 9; 191: E989-1004. doi: 10.1503/cmaj.181504
    2. Provinciali L, Carlini G, Tarquini D et al. Neurol Sci (2016) 37: 1581. https://doi.org/10.1007/s10072-016-2614-x
    3. Boersma I, Miyasaki J, Kutner J, Kluger B. Neurology (2014) 83(6): 561. doi: 10.1212/WNL.0000000000000674
    4. www.who.int/cancer/palliative/definition/en Accessed Oct 16, 2019.
    5. https://www.cspcp.ca/wp-content/uploads/2019/06/CSPCP-Key-Messages-PC-an... Accessed Oct 16, 2019.

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 191 (36)
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Canadian guideline for Parkinson disease
David Grimes, Megan Fitzpatrick, Joyce Gordon, Janis Miyasaki, Edward A. Fon, Michael Schlossmacher, Oksana Suchowersky, Alexander Rajput, Anne Louise Lafontaine, Tiago Mestre, Silke Appel-Cresswell, Suneil K. Kalia, Kerrie Schoffer, Mateusz Zurowski, Ronald B. Postuma, Sean Udow, Susan Fox, Pauline Barbeau, Brian Hutton
CMAJ Sep 2019, 191 (36) E989-E1004; DOI: 10.1503/cmaj.181504

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Canadian guideline for Parkinson disease
David Grimes, Megan Fitzpatrick, Joyce Gordon, Janis Miyasaki, Edward A. Fon, Michael Schlossmacher, Oksana Suchowersky, Alexander Rajput, Anne Louise Lafontaine, Tiago Mestre, Silke Appel-Cresswell, Suneil K. Kalia, Kerrie Schoffer, Mateusz Zurowski, Ronald B. Postuma, Sean Udow, Susan Fox, Pauline Barbeau, Brian Hutton
CMAJ Sep 2019, 191 (36) E989-E1004; DOI: 10.1503/cmaj.181504
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