Treadmill Training For Neurological Disorders And Parkinson’s Disease

Benefits of Treadmill Training for Parkinson’s Disease

Treadmill training is an integral part of rehabilitation for neurological disorders (Swinnen et al. 2012). People with parkinsons disease do benefit from treadmill training as in improves their gait, speed and motor coordination (Herman et al.2007). The motor symptoms include akinesia due to reduced levels of the neurotransmitter dopamine and dyskinesia which is an effect of long-term use of medication used for treatment that exposes the body to high dopamine levels leading to excesses of motor movement (Boonstra, van der Kooij, Munneke, and Bloem, 2008). Evidence-based approach to parkinsons disease shows that use of treadmill training can correct gait and posture disturbances (Mehrholz et al. 2010). The use of the treadmill training exercises for the patient in this study was therefore justified.

Lower limb rehabilitation for neurological disorders is a multifactorial undertaking. The devices used include treadmill trainers, ankle rehabilitation trainers, foot-plate based trainers, over ground gait trainers and stationary trainers (Li, Chen, and Fan, 2017). The hospital has one of these, a treadmill. The hospital however only has one option to use and only one treadmill limiting the effectiveness of the provision of care. This is a clear lack of healthcare infrastructure. This is evidenced by the poor state of the treadmill, the faulty sockets that stop functioning during sessions and the lack of information technology like a working computer. Use of improved equipment will greatly impact the performance and outcome of the therapy sessions. In Saudi Arabia, there are some small hospitals that do not have computer-based patient record systems to save patients’ information and support different healthcare providers (Bah et al.2011). Therefore, the organization and accessibility of health data are still poor, resulting in inappropriate decisions and medical errors in relation to the patient (Sujansky 1998).

 According to Decker, Cignetti, and Stergiou, (2012), safety in the rehabilitation sessions is paramount. A safety harness should be incorporated in the treadmill as a safety measure against falls. It, however, has the disadvantage of slightly altering lower limb gait kinetics (Decker, Cignetti, and Stergiou, 2012).  The treadmill in the hospital lacked crucial safety devices including a safety belt or harness. If a harness would have been availed then the patient would have no trouble adjusting in case of power failure or dysfunctions. Treadmill training is weight based as patients have to balance their body weight on rails hence a safe railing is required or it can be dangerous (El-Shamy 2017). Safety incidents are quite rare but may cause severe harm to both the patient and healthcare workers. Fractures due to treadmill training have been reported (El-Shamy 2017). In this case study, the patient nearly fell during the session due to lack of supports on the treadmill. The patient’s traditional cloth that resembles a dress also adds to this risk as it could be caught in the strong rollers of the treadmill, bringing the patient down or causing physical harm (Luciani et al. 2012). Every year, there are numerous accidents to employees, corers, and service users from using work equipment in health and social care.  Many are serious and some are fatal.

Challenges of Treadmill Training for Neurological Disorders

The environment around the treadmill is also an important contributor to the near miss. The treadmill was placed in a small room with a faulty socket. The small room did not allow for proper space for maneuvering and the faulty socket caused failure of the treadmill that almost made the patient fall off. According to Evans, Hodgkinson, Lambert, and Wood, (2001), impaired hospital setting mobility is one of the risks of patient injury including the risk of falls. A study was done by Al jhdali, Al Amoudi and Abdulbagi (2009) in King Abdulazzi University Hospital, Jeddah, aimed at finding the etiology of falls in the hospital setting. The results showed the environment including wet floors, malfunctioning systems, and lowered rails played a major role. Using the right, well-maintained equipment operated by trained staff can help prevent accidents and reduce the personal and financial costs.

Hospital Staff.

Saudi Arabia has very large staffing issues in all cadres of health, including physiotherapists (Alghadir et al. 2015). Employment of unqualified or inexperienced physiotherapy technicians is therefore a reality (Alghadir et al. 2015). It is suggested that physiotherapy technicians who have diploma certifications have issues dealing with challenging working environment and communication because their educational curriculum does not have the required framework to adequately deal with those issues (Bindawas et al. 2013). Patient safety and the qualification of the caring physiotherapists go together (Ellis et al. 2001). The physiotherapist in our case had a one-year working experience which is insufficient to empower one with the necessary skillset to effectively deal with all issues of patient care.

The health system in Saudi Arabia has staffing problems as seen by the large number of expatriate and foreign physicians (Al Yousuf, Akerele, and Al Mazrou, 2002). As of 1998, only 20% of physicians were of Saudi origin. This creates problems with communication, culture and overall patient care. This particular hospital in the case study has only one physiotherapist and five physiotherapy technicians. This lack of adequate staffing directly impacts patient care as protocols are ignored, assessments not properly done and a backlog of patients leading to long wait time and delays. The patient had to wait 4 days before an appointment could be scheduled due to lack of enough staff. In this way, the impromptu appointment could have been avoided and proper planning of care done (Aiken, Clarke, and Sloane, 2002).

Communication is an important health skill as it facilitates all health care interactions, between patients and healthcare providers and between the professionals themselves. Lack of adequate or appropriate communication leads to breakdown of flow of information and system errors and human errors occur as a result (La Pietra et al. 2005). It is estimated that close to 80% of these system and human errors are caused by miscommunication (La Pietra et al. 2005). This emphasizes the importance of encouraging acquisition of an array of good communication skills. A study by Potter, Gordon, and Hamer (2003) on the patient perspective of who they regard as a good physiotherapist yielded some conclusive results on the qualities of care that are desirable. The qualities included communication ability, professional behavior and the quality of service provided. It was noted good communication ability was the main quality patients desired.

Importance of Healthcare Infrastructure in Treadmill Training

Another aspect of communication is interprofessional communication. The physiotherapist and the departments must have appropriate communication channels to ease the flow of information and procedures. Appropriate care should be multidisciplinary for the management of motor and non-motor symptoms of Parkinson’s disease (van der Marck et al. 2013). The neurology, the physiotherapy department, nursing care team and social workers are all required if the care is to be of good quality. The referral from the neurology team that assessed and diagnosed him was a paper referral and only provided a patient description. A collaborative effort should have been made to ensure proper care as deficient collaboration only hurts the patient  

Care planning was another important contributor to the near miss. A proper care plan should have an impact on the patient outcome by being patient-centered, improve physical, psychosocial health and improve the capabilities of the patients with chronic illnesses (Coulter et al. 2013). The patient’s care plan was not correctly planned. Improper care planning led to the patient consultation without proper preparation. The patient arrived in clothes that were not suitable for treadmill training, had not taken their medication, had not had breakfast and due to these factors, he was dizzy during the session and had a near fall event.

Patient Factors.

Patient factors that contribute to the near-miss include the disease diagnosis of Parkinson’s disease, patient neglect, and cultural factors. Parkinson’s disease is a chronic neurological disorder that is diagnosed clinically (Jankovic 2008). Symptoms include resting tremors, rigidity, loss of reflexes, and bradykinesia. These symptoms are diagnostic. However, other motor symptoms can present, including difficulty swallowing (dysphagia), freezing, involuntary muscle contractions (dystonia), festination gait and reduced facial expression (hypomimia) among others (Jankovic 2008). The patient in the case study has difficulty in movement due to gait difficulty. This is the most incapacitating symptom of Parkinson’s disease and is distressing to patients (Boonstra, van der Kooij, Munneke, and Bloem, 2008). The distressing aspects include akinesia due to reduced levels of the neurotransmitter dopamine and dyskinesia which is an effect of long-term use of medication used for treatment that exposes the body to high dopamine levels leading to excesses of motor movement (Huot et al. 2013).

In the context of the case study, the disease process predisposes the patient to falls due to the gait disability. According to Bloem, Hausdorff, Visser, and Giladi, (2004), the most frequent episodes due Parkinson’s disease are falls and freezing. This means the patient was already at risk of falls and imbalance and this was a large contributor to the near miss. The patient also reported not taking their medication that morning compounding the effects of the disease process. He also noted that whenever he had not taken his medication, dizzy spells occurred.

Quality care is the delivery of care that surpasses the patients’ expectations and achieves the highest possible outcomes using the available resources. Clarke (2014) described a model of care termed the 6 Cs. They include care, competence, compassion, communication, courage, and commitment and serve as guidelines for patient-centered in whatever discipline including physiotherapy (Kidd, Bond, and Bell, 2011). Patient-centered care is a principle whereby the patient is allowed to be involved in their care, choose the best options available according to their circumstances and preferences. This fulfills the principles of compassion and ensures there is no patient neglect and or breach of ethics.

Safety Measures in Treadmill Training

The patient was not involved in his own care. Some degree of neglect was present in the case. This is contrary to patient-centered care. A schedule should have been available that would specify the best possible approach to care using the patient input as a guide. However, from the case study, the patient was contacted at a time that was not appropriate to him leading to errors on the patient part. He was not able to take medication, breakfast or wear appropriate clothing. He was a silent spectator in his own care and that was detrimental to the near miss event. It has been shown that patient-centered care especially in chronic illnesses leads to better outcomes, patient satisfaction and fosters better self-management (Levinson, Lesser, and Epstein, 2010).

Saudi Arabia is a primarily an Islamic state and confers to the traditional and religious practices that come with it. The dressing is also traditional and standardized. The men wear an ankle-long shirt resembling a dress called “thawb”, a long cloak called a “bisht” and a skullcap called a “kufiyyah” with a cord circlet called ‘igal” (National clothing.org. 2018). The patient in the case study, conforming to tradition, wore this traditional attire which was against treadmill protocol as it would stick in the moving parts of the treadmill causing falls or injuries and also limit his movement. The correct dressing would have been sportswear as the physiotherapy technician had instructed, which would have provided more freedom of movement on the treadmill and guarantee safety.

To make sure that the near miss does not occur causing further harm, death, disability or legal litigation, several measures have to be put in place. Most of the errors noted in the case study represent modifiable risk factors for a near fall. Most can be removed or improved. Changes are therefore warranted with regards to the following aspects to avoid this type of event from happening in the future:

1. Infrastructure development

The Saudi health system is currently undergoing rapid modernization and improvements aimed at making sure the growing population receives good care (Jannadi, Alshammari, Khan, and Hussain, 2008). The government is the largest provider of health services in this country with the others being the private sector and other organizations. Availability of health infrastructure has a positive impact on patient outcomes and is one of the major determinants of health. The hospital environment is a major factor for causes of falls and injuries should be improved (Al jhdali, Al Amoudi and Abdulbagi, 2009). This includes patient-friendly architecture with non-slippery floors, building rails, ramps and well-conditioned rooms that patients can feel safe in.  

The equipment used for physiotherapy should be varied to allow for diversity and flexibility in case one breaks down. They include treadmill trainers, ankle rehabilitation trainers, foot-plate based trainers, over ground gait trainers and stationary trainers (Li, Chen, and Fan, 2017). The hospital should allocate funds to replace broken down machines, maintain existing ones and add more equipment. Sourcing for health financing to meet this recommendation is, however, a challenge. Several avenues could be sought including private financing and government funding. An example is the UK’s private finance initiative (PFI) that provided for the building of hospitals and increased their functionality (Barlow and Köberle-Gaiser, 2008).

1. Human resource development including staffing, training, and evaluation.

Staff Qualifications and Patient Safety in Treadmill Training

The Saudi health workforce is a growing force and focus on human resource development should be emphasized. Health workers in this country are mostly expatriate with varied nationalities and only a fraction are nationals. According to World Health Organization, (2010), health workforce is an integral part of the health system building blocks together with health information, service delivery, medical supplies and technologies, health care financing and management. It is therefore beneficial to the entire hospital system to strengthening it leading to better health outcomes (World Health Organization, 2010).

The health workforce needs to be improved through training more specialists, in this case, more physiotherapists and physiotherapy technicians. This ensures the free flow of work and effective patient care. With limited workers like in the case study, systematic errors and patient mishandling due to fatigue, burnout and job dissatisfaction can ensue (Paris and Hoge, 2010). The physiotherapists should be increased in number to the WHO recommended ratio for the population. Work-based training to build capacity and horn skills by the health professionals is required (Matovu et al. 2013).

Evaluation of the human resource is another recommendation that will minimize system errors (World Health Organization 2007). An example is the working ethics of the physiotherapist and physiotherapy technician who should have been supervised and evaluated. The errors such as not following safety protocols and allowing inappropriate dressing to be used during the session should have been flagged and questions to avoid a repeat of such.

1. Intra and interdepartmental communication in patient care and the employment of a multidisciplinary approach to care.

A multidisciplinary approach to the management of Parkinson’s disease is the recommended approach to care (Marck et al. 2013). This is due to the complex nature of the disease presentation and management approaches. The patients have both motor and non-motor presentations needing several specialists to be involved in the care including physicians, neurologist, physiotherapists, occupational therapist, nursing care team, social workers, and other supporting professionals (Seppi et al, 2011).

Miscommunication between these professionals becomes the source of system errors in most hospital settings (Reeves and Lewin 2004). For there to be quality patient care there should be smooth handover from one professional to another (Rice et al. 2010). The health professionals involved in the case should be aware of all interventions happening to the patient so that they can either maintain or improve on their own plan of care. In the case study, a better referral system between the neurology and physiotherapy department should be in place to ensure better continuity of care.

1. Strengthening the care planning process.

Care plan in our case study was not effective. A systematic approach to care planning should be implemented. System failures are maor causes of this errors with up to 80% of clinical errors estimated to be due to the failure of information flow and personal miscommunication between hierarchies and professional health care, which means that they are essentially caused by human error (La Pietra et al. 2005). Mistakes in the organizational plan are therefore a large factor leading to patient harm and they represent failure of the system. The health system should be involved as a whole to guarantee patient safety, with involvement of both the management and the staff (Nieva and Sorra 2002).

Effective Communication in Physiotherapy

Health planning to bring about order in the system should be employed. They should be able to address issues with resource capacity planning, control, management and organizing responsibilities (Hans, van Houdenhoven, and Hulshof, 2012). An example of this failure is the physiotherapy technician having the responsibility of contacting the patients and scheduling visits, a responsibility that is not his domain.

1. Using safety protocols for physiotherapy devices

In the case study, treadmill design was one of the causative factors of the near miss event. The treadmills did not have safety harnesses or safety rail to prevent the patient from falling off. The treadmill was connected to a faulty socket that malfunctioned suddenly and almost caused harm. The recommendation is to equip the devices with safety harnesses and rails to prevent falling and to allow weight bearing (Druzbicki et al. 2013). An example is using automated treadmills that disconnect when the patient speed and that of the machine are not in sync or a cord that stops the machine in the patient falls or is pulled back by the belt.

These devices should be routinely inspected as per manufacturer specifications. This would have prevented the dysfunctions during sessions, for example, the socket failures. Hospitals should have a clinical engineering department that is mandated to carry out inspections and installations (Taghipour, Banjevic, and Jardine, 2011). These devices should be prioritized to prevent failure in critical devices that without them the service cannot continue. The hospital should have a medical equipment management program that is run by the clinical engineering program to keep track of all devices (Taghipour, Banjevic, and Jardine, 2011).

1. Adopting a more modern health information and storage system

The hospital in question relies on paper documentation as the mode of information storage. This is an issue in most Saudi Arabian hospitals whereby despite the positive effects of an electronic information system, the use and uptake is low (Khalifa 2013). The study identified that several barriers underpin this observation including beliefs and attitudes, hospital management, financial constraints and legal hurdles.

An effective information system is crucial especially in physiotherapy as the condition and management is chronic and requires close monitoring of progress (Hillestad et al. 2005). A paper-based information system could lead to serious systemic errors and patient mismanagement. It is therefore recommended that the hospital put in place a framework that will allow them to adopt an electronic information system (Parente and McCullough 2009).

Conclusion.

A near miss event is an unexpected event which might lead to risk, harm injury or illness for a patient. The present paper sought to analyze a near miss event involving a patient attending a physiotherapy session at a hospital in Saudi Arabia with a view of identifying the factors that caused the near miss and recommendations of how to mitigate those factors.

The factors identified as leading to the near miss event included equipment and supplies, patient factors and the hospital staff. The equipment used lacked proper safety measures and the environment where the treadmill was placed was also unsafe. The hospital staffing was inadequate and inexperienced enough to and ignored protocols. There was ineffective communication in view of a multidisciplinary approach to care and the care planning was ineffective. The patient factors included the Parkinson’s disease process that predisposed him to falls, patient neglect and lack of patient-centered care and his culture that which involves wearing clothing not suitable for a treadmill.

Conclusion

The recommendations that would help mitigate these risk factors included improving health infrastructure and health workforce, employing better safety protocols for physiotherapy devices, strengthening the care planning process and communication and finally adopting a modern health information system. 

References

Aiken, L. H., Clarke, S. P., & Sloane, D. M., 2002. Hospital staffing, organization, and quality of care: Cross-national findings. Nursing Outlook, 50(5), p.187-194. doi:10.1067/mno.2002.126696

Al Jhdali, H., Al Amoudi, B., & Abdulbagi, D., 2012. Falls epidemiology at King Abdulaziz University Hospital, Jeddah-Saudi Arabia-2009. Life Sci J, 9(2), p.1174-1178.

Al Yousuf, M., Akerele, T.M. & Al Mazrou, Y.Y., 2002‎. Organization of the Saudi health system. https://www.who.int/iris/handle/10665/119213

Alghadir, A., Zafar, H., Iqbal, Z.A. and Anwer, S., 2015. Physical therapy education in Saudi Arabia. Journal of physical therapy science, 27(5), pp.1621-1623.

Bindawas, S.M., Vennu, V. and Azer, S.A., 2013. Are physical therapy interns competent in patient management skills? Assessment of the views of clinical and academic physical therapists. Journal of physical therapy science, 25(5), pp.649-655.

Bloem, B. R., Hausdorff, J. M., Visser, J. E. and Giladi, N., 2004. Falls and freezing of gait in Parkinson’s disease: A review of two interconnected, episodic phenomena. Movement Disorders, 19: p.871-884. doi:10.1002/mds.20115

Boonstra, T. A., van der Kooij, H., Munneke, M., & Bloem, B. R., 2008. Gait disorders and balance disturbances in Parkinson’s disease: clinical update and pathophysiology. Current Opinion in Neurology, 21(4), p.461-471. doi: 10.1097/WCO.0b013e328305bdaf

Clarke, C., 2014. Promoting the 6Cs of nursing in patient assessment. Nursing Standard (2014+), 28(44), p.52.

Coulter, A., Entwistle, V. A., Eccles, A., Ryan, S., Shepperd, S., & Perera, R., 2013. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews (5). doi:10.1002/14651858.CD010523

Decker, L. M., Cignetti, F., & Stergiou, N., 2012. Wearing a safety harness during treadmill walking influences lower extremity kinematics mainly through changes in ankle regularity and local stability. Journal of NeuroEngineering and Rehabilitation, 9(1), p.8. doi:10.1186/1743-0003-9-8

Ellis, B. and Connell, N.A.D., 2001. Factors determining the current use of physiotherapy assistants: Views on their future role in the South and West UK region. Physiotherapy, 87(2), pp.73-82.

El-Shamy, S.M., 2017. Effects of antigravity treadmill training on gait, balance, and fall risk in children with diplegic cerebral palsy. American journal of physical medicine & rehabilitation, 96(11), pp.809-815.

Evans, D., Hodgkinson, B., Lambert, L., & Wood, J., 2001. Falls risk factors in the hospital setting: a systematic review. International journal of nursing practice, 7(1), p.38-45.

Forster, A. and Young, J., 1990. The role of community physiotherapy for stroke patients. physiotherapy, 76(8), pp.495-497.

Hans, E. W., van Houdenhoven, M., & Hulshof, P. J. H., 2012. A Framework for Healthcare Planning and Control. In R. Hall (Ed.), Handbook of Healthcare System Scheduling (pp. 303-320). Boston, MA: Springer US.

Herman, T., Giladi, N., Gruendlinger, L. and Hausdorff, J.M., 2007. Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson’s disease: a pilot study. Archives of physical medicine and rehabilitation, 88(9), pp.1154-1158.

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R., 2005. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs, 24(5), p.1103-1117.

Jankovic, J., 2008. Parkinson’s disease: clinical features and diagnosis. Journal of Neurology, Neurosurgery & Psychiatry, 79(4), p.368-376. doi:10.1136/jnnp.2007.131045

Jannadi, B., Alshammari, H., Khan, A., and Hussain, R., 2008. Current Structure and Future Challenges for the Healthcare System in Saudi Arabia. Asia Pacific Journal of Health Management, 3(1), p.43-50

Khalifa, M., 2013. Barriers to Health Information Systems and Electronic Medical Records Implementation. A Field Study of Saudi Arabian Hospitals. Procedia Computer Science, 21, p.335-342. doi:https://doi.org/10.1016/j.procs.2013.09.044

Kidd, M. O., Bond, C. H., & Bell, M. L., 2011. Patient’s perspectives of patient-centeredness as important in musculoskeletal physiotherapy interactions: a qualitative study. Physiotherapy, 97(2), p.154-162. doi: 10.1016/j.physio.2010.08.002

La Pietra, L., Calligaris, L., Molendini, L., Quattrin, R. and Brusaferro, S., 2005. Medical errors and clinical risk management: state of the art. Acta otorhinolaryngologica italica, 25(6), p.339.

Levinson, W., Lesser, C., and Epstein, R., 2010. Developing Physician Communication Skills for Patient-Centered Care. Health Affairs, 29(7), p.1310-1318. doi:10.1377/hlthaff.2009.0450

Li, J., Chen, D., & Fan, Y., 2017. An Open-Structure Treadmill Gait Trainer: From Research to Application. Journal of Healthcare Engineering, 2017, 12. doi:10.1155/2017/9053630

Luciani, L.B., Genovese, V., Monaco, V., Odetti, L., Cattin, E. and Micera, S., 2012. Design and Evaluation of a new mechatronic platform for assessment and prevention of fall risks, Journal of neuroengineering and rehabilitation, 9(1), p.51.

Marck, M. A., Bloem, B. R., Borm, G. F., Overeem, S., Munneke, M. and Guttman, M., 2013. Effectiveness of multidisciplinary care for Parkinson’s disease: A randomized, controlled trial. Movement Disorders, 28(5), p.605-611. doi: 10.1002/mds.25194

Matovu, J. K., Wanyenze, R. K., Mawemuko, S., Okui, O., Bazeyo, W., & Serwadda, D., 2013. Strengthening health workforce capacity through work-based training. BMC International Health and Human Rights, 13(1), p.8. doi:10.1186/1472-698x-13-8

Mehrholz, J., Friis, R., Kugler, J., Twork, S., Storch, A. and Pohl, M., 2010. Treadmill training for patients with Parkinson’s disease. Cochrane Database Syst Rev, 1.

National clothing.org., 2018. Accessed 7 may, 2018, from https://nationalclothing.org/middle-east/33-saudi-arabia/45-traditional-clothing-of-saudi-arabia-men-in-white,-women-in-black.html

Nieva, V.F. and Sorra, J., 2003. Safety culture assessment: a tool for improving patient safety in healthcare organizations. BMJ Quality & Safety, 12(suppl 2), pp.ii17-ii23.

Parente, S.T. and McCullough, J.S., 2009. Health information technology and patient safety: evidence from panel data. Health Affairs, 28(2), pp.357-360.

Paris, M., & Hoge, M. A., 2010. Burnout in the mental health workforce: A review. The journal of behavioral health services & research, 37(4), p.519-528.

Potter, M., Gordon, S., & Hamer, P., 2003. The physiotherapy experience in private practice: The patients’ perspective. Australian Journal of Physiotherapy, 49(3), p.195-202. doi:https://doi.org/10.1016/S0004-9514(14)60239-7

Rascol, O., Brooks, D. J., Korczyn, A. D., De Deyn, P. P., Clarke, C. E., & Lang, A. E., 2000. A five-year study of the incidence of dyskinesia in patients with early Parkinson’s disease who were treated with ropinirole or levodopa. New England Journal of Medicine, 342(20), p.1484-1491.

Reeves, S. and Lewin, S., 2004. Interprofessional collaboration in the hospital: strategies and meanings. Journal of Health Services Research & Policy, 9(4), pp.218-225.

Rice, K., Zwarenstein, M., Conn, L.G., Kenaszchuk, C., Russell, A. and Reeves, S., 2010. An intervention to improve interprofessional collaboration and communications: a comparative qualitative study. Journal of Interprofessional Care, 24(4), pp.350-361.

Seppi, K., Weintraub, D., Coelho, M., Perez?Lloret, S., Fox, S.H., Katzenschlager, R., Hametner, E.M., Poewe, W., Rascol, O., Goetz, C.G. and Sampaio, C., 2011. The Movement Disorder Society Evidence?Based Medicine Review Update: Treatments for the non?motor symptoms of Parkinson’s disease. Movement Disorders, 26(S3).

Sujansky, W.V., 1998. The benefits and challenges of an electronic medical record: much more than a” word-processed” patient chart. Western Journal of Medicine, 169(3), p.176.

Swinnen, E., Beckwée, D., Pinte, D., Meeusen, R., Baeyens, J.P. and Kerckhofs, E., 2012. Treadmill training in multiple sclerosis: can body weight support or robot assistance provide added value? A systematic review. Multiple sclerosis international, 2012.

Taghipour, S., Banjevic, D., & Jardine, A. K. S., 2011. Prioritization of medical equipment for maintenance decisions. Journal of the Operational Research Society, 62(9), p.1666-1687. doi:10.1057/jors.2010.106

van der Marck, M. A., Munneke, M., Mulleners, W., Hoogerwaard, E. M., Borm, G. F., Overeem, S., … & IMPACT Study Group., 2013. Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial (IMPACT). The Lancet Neurology, 12(10), p.947-956.

World Health Organization, 2007. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines.

World Health Organization, 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization.