At the 5th World Parkinson Congress in Kyoto, Japan in 2019, I met many persons with Parkinson's disease (PwPs) from all over the world, and we discussed a variety of issues regarding the disease. One substantial problem that came up regularly was rehabilitation. Many PwPs asked me what kind of rehabilitation I recommended, how many sessions and how long is enough, etc. Most importantly, they asked where they can access rehabilitation specialized for PwPs. As a movement disorder specialist, I always tell my patients to undergo rehabilitation. But honestly, the access to rehabilitation specialized to PwPs is very limited in Japan.

In Japan, rehabilitation for PwPs is covered by two national insurances: the medical insurance system and the nursing-care insurance system. The national medical insurance does not cover rehabilitation for chronic diseases such as Parkinson's disease (PD) in the outpatient clinic. It only covers limited terms (usually 1 to 3 months) for "recovery rehabilitation" from an acute medical condition, such as bone fracture, stroke, and pneumonia. Some PwPs who fulfill this requirement, can be referred for the same by their doctors. However, recovery rehabilitation is mostly done for those in inpatient care. Because of a shortage of physical, occupational, and speech therapists, only a few hospitals provide recovery rehabilitation in the outpatient clinic. We usually refer our patients to rehabilitation doctors, who then prescribe them rehabilitation services. In addition, as most hospitals focus on stroke and orthopedic conditions, there are very few hospitals providing PD specific rehabilitation. Most outpatient rehabilitation is provided by the national nursing-care insurance system. We refer PwPs to the care manager, a coordinator of resources of the nursing-care insurance system in the local area, who then finds available rehabilitation services for each patient. PwPs can use these services with a 10-30% payment of the total cost, along with some discount depending on their severity and incomes. Typically, most PwPs enjoy rehabilitation sessions in the daycare center only 2 to 3 times a week, and the quality of the same varies from center-to-center and region-to-region.

Recently, my friend, Fernando Cubillos, a former Senior Director of Clinical Affairs of the Parkinson's Foundation, asked me about differences among Asian countries regarding a referral to rehabilitation for PwPs. I asked my friends in various Asian countries about the same, to which they kindly replied. The summary of each country is given below.

South Korea: While it is post-stroke care that is still mainstream for rehabilitation doctors in Korea, they have quite a nice referral system for rehabilitation for/of PwPs. In Korea, PwPs have access to both, a personalized rehabilitation program and a small group exercise program. In some specialized centers, they provide a sophisticated rehabilitation program arranged by a multidisciplinary team for PwPs, but the detailed program differs among the centers. However, there is a problem with reimbursement from the national insurance system.

Philippines: Neurologists can refer PwPs to rehabilitation specialists. The insurance system pays for their therapy sessions but requires their insurance approval and a neurologist's referral. However, PwPs may not always go to rehabilitation due to financial reasons. The other problem is that not many physical therapists are specializing only in PD. Like Korea and Japan, this is mainly because the most common causes of referral to rehabilitation in the Philippines are injuries, orthopedic causes, and stroke.

Indonesia: There are no specific guidelines for referral to rehabilitation for PwPs. In some centers, PwPs may be referred to a rehabilitation doctor if needed, who then prescribes the specific exercise depending on the clinical symptoms of each patient. They mostly perform physical therapy around balance exercises, gait training, range of motion, and strengthening. However, not all centers have special teams for managing the rehabilitation of PwPs.

China: There is no referral system for rehabilitation for PwPs. In the hospital, the department of rehabilitation provides rehabilitation for all kinds of patients. PD is covered in both, inpatient and outpatient clinics, but it is uncommon to admit PwPs to the rehabilitation unit.

Taiwan: In a PD center, a PD-special rehabilitation clinic is provided by/in the neurology department of a PD center twice a week. They can directly refer PwPs to physical therapists for rehabilitation without going through rehabilitation doctors. In addition, a rehabilitation group program is also held in PD centers once a week. However, this is not applicable to all hospitals.

Thailand: Not all hospitals have rehabilitation consultation, and most of the movement specialists send PwPs to rehabilitation only when they have specific problems, such as those related to gait, speech, and swallowing. However, some hospitals have a specialized rehabilitation unit for PwPs with a multidisciplinary team approach.

Malaysia: They do not have many therapists who are specialized in PD. Therefore, most PwPs seek rehabilitation from general therapists. There are some patients who have walk-ins with therapists in private centers. Yet, the majority are referred by neurologists or physicians. Basically, access to rehabilitation is relatively fast, but patients usually must pay on their own. The main problems that limit the frequency of rehabilitation are cost and distance from the rehabilitation center.

 As showcased by the examples given above by my colleagues across Asia, referral to rehabilitation for PwPs is not uniform and varies from country to country. Even within countries, it differs depending on the centers. I feel that it may be time to conduct a survey regarding this referral system and discuss how to improve access to rehabilitation for PwPs both across Asia and within each country in order to better serve the Parkinson’s community.

Genko Oyama, M.D., Ph.D., FAAN is an associate professor, Department of Neurology, Department of Neurodegenerative and Demented Disorders, Department of Home medical care System based on Information and Communication Technology, Department of Drug Development for Parkinson's Disease, Juntendo University Faculty of Medicine Courtesy associate professor, Department of Neurology, University of Florida. He was a committee member at the 5th World Parkinson Congress in Kyoto, Japan. He is currently involved as a clinical science subcommittee member for the 6th World Parkinson Congress in Barcelona.

Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not necessarily reflect the opinions of the World Parkinson Coalition®