Why Physiatrists Should Lead Parkinson’s Care

A group of internationally recognized Parkinson’s specialists, including Dutch neurologist Bas Bloem, one of the most influential figures in the field, is calling for a specific kind of doctor to take charge of coordinating Parkinson’s care: the physiatrist. What is a physiatrist? According to rehabhospital.org, “A physiatrist (pronounced fiz-zy-AT-rist) is a board-certified medical doctor (MD) or doctor of osteopathic medicine (DO) who has completed four years of specialized residency training in Physical Medicine and Rehabilitation (PM&R).” The website goes on to describe them as – they are not physical therapists; they are specialist physicians who have chosen to focus their medical expertise on a single goal: helping patients regain maximum function and quality of life lost to injury, illness, or disability. Their specialty focuses on the complex interplay between the nerves, muscles, bones, and brain.

The recommendation comes in a position paper published this month in npj Parkinson’s Disease called “The physiatrist in Parkinson’s multidisciplinary care: from orchestra member to orchestra director.”

The research paper wasn’t a clinical trial, and there were no patients involved. It was more of an argument made by Daniele Volpe, Bas Bloem, and several of their colleagues from Italy, the Netherlands, and the United States, about how Parkinson’s treatment should be organized as the disease progresses and the number of specialists involved grows.

The problem they’re describing is familiar to anyone who has sat in a Parkinson’s patient’s living room during a bad week. A neurologist manages the medication. A physical therapist works on balance. An occupational therapist adjusts the kitchen. A speech therapist handles swallowing. Nobody is necessarily talking to anybody else. “A lack of effective coordination among team members and across care settings is a persistent limitation,” the group of researchers writes, citing a 2020 systematic review of integrated Parkinson’s care.

The paper doesn’t call for neurologists to be replaced. They still run the diagnosis, the medications, and advanced treatments like deep brain stimulation. What Volpe, Bloem, and the rest are proposing is a second role, one focused entirely on the day-to-day disability that builds up over years and that medication alone often can’t fix.

They use an image from conductor Leonard Bernstein, who said balancing an orchestra depends on knowing all instruments’ strengths and limits. Early on, the physiatrist might be one instrument among many. Later, as falls, freezing, and swallowing problems pile up, the authors say the physiatrist should become the conductor, the one holding the full score.

To make that concrete, the paper lays out a staged plan tied to how disabled a patient currently is. At diagnosis, the neurologist leads, with the physiatrist involved for education and activity planning. As disability emerges, physiatrists and physical therapists share the lead, especially for working-age patients still managing jobs and families around the disease. Once falls, freezing, and frequent rehab needs enter the picture, the physiatrist takes over coordination of the broader team. And for advanced disease complicated by dementia or multiple other health conditions, a geriatrician leads medical care, while the physiatrist continues to design the rehab plan around it. They also built a decision tree clinics can use to sort patients into outpatient visits, day programs, hospital stays, or home-based care, triggered by specific red flags like repeated falls or new trouble swallowing, rather than by disease stage alone.

The strongest direct evidence the authors cite is a small, older study out of a Veterans Affairs Parkinson’s center, 43 patients followed for about a year under combined neurologist and physiatrist care. Roughly three-quarters held steady or improved on a standard motor exam. It’s a real result. It’s also an uncontrolled study at one site.

They acknowledge that team-based care is the way to go when it comes to Parkinson’s patients, but based on the results of that study, they conclude that the physiatrist should be the one to lead that team. “High-quality evidence specifically evaluating physiatrist-led rehabilitation models in PD remains limited,” the authors write, calling for actual randomized trials that, as of this paper, don’t exist yet.

The paper closes with something most position papers skip, a direct response from someone living with the disease. Gary Boyle, of the European Parkinson’s Disease Association, picks up the orchestra metaphor and runs with it, arguing that healthcare systems routinely expect a handful of specialists to deliver what really takes a full, well-resourced team.

It’s a small addition, but it changes the tone of the paper from clinicians talking to each other to something closer to clinicians making a case to patients directly. “Here, we argue that involvement of physiatrists could play a key role in leading the multidisciplinary rehabilitation care team in PD,” the authors say,” Given their scope of practice, broad knowledge across all fields of rehabilitation, and their willingness to accommodate all aspects of a patient’s life that may be affected by the disease.”

The authors call for pragmatic trials testing physiatrist-coordinated care head-to-head against usual care, along with changes to how physiatrists are trained and how health systems recognize the role at all. None of that exists yet. What does exist is a detailed, testable model that clinics in different countries, with very different health systems, could start trying now.

Whether the title ends up being physiatrist or something else entirely, the underlying question the paper raises is hard to argue with. Parkinson’s care already involves an orchestra of specialists. Someone has to conduct it.