Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis.

BACKGROUND: Movement disorders (Parkinson's disease, essential tremor, primary dystonia) are a debilitating group of conditions that are progressive in nature. The mainstay of treatment is best medical therapy; however, a number of surgical therapies are available, including deep brain stimulation. Economic evaluations are an important aspect of evidence to inform decision makers regarding funding allocated to these therapies. OBJECTIVE: This systematic review and meta-analysis evaluated the cost effectiveness of including deep brain stimulation compared with best medical therapy for movement disorder indications in the adult population. METHODS: Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials were queried. Only economic evaluations reporting incremental cost-effectiveness ratios for including deep brain stimulation versus best medical therapy for movement disorders were included. Studies were reviewed in duplicate for inclusion and data abstraction. Data were harmonized using the Consumer Price Index and Purchasing Power Parity to standardize values to 2022 US dollars. For inclusion in meta-analyses, studies were required to have sufficient data available to calculate an estimate of the incremental net benefit. Meta-analyses of pooled incremental net benefit based on the time horizon were performed. The study was registered at PROSPERO (CRD42022335436). RESULTS: There were 2190 studies reviewed, with 14 economic evaluations included following a title/abstract and full-text review. Only studies considering Parkinson's disease were available for the meta-analysis. Quality of the identified studies was low, with moderate transferability to the American Healthcare System, and certainty of evidence was low. However, studies with a longer time horizon (15 years to lifetime) were found to have significant positive incremental net benefit (indicating cost effectiveness) for including deep brain stimulation with a mean difference of US$40,504.81 (95% confidence interval 2422.42-78,587.19). CONCLUSIONS: Deep brain stimulation was cost effective for Parkinson's disease when considered over the course of the patient's remaining life after implantation. TRIAL REGISTRATION: Clinical Trial Registration: PROSPERO (CRD42022335436).

Geospatial Analysis of Persons with Movement Disorders Living in Underserved Regions.

Background: Movement disorders persons from underserved areas have increased barriers to access tertiary care. There is currently limited data on the geographic and demographic profile of movement disorders persons from underserved areas. Methods: A retrospective chart review of the geographic and demographic profile of consecutive cases seen between 2002-2017 at the University of Florida Norman Fixel Institute for Neurological Diseases (UF-NFIND) was performed. Information collected included age, sex, diagnosis, zip code, treatment received, and insurance information. The distances between each person's home residence and the nearest movement disorders center of excellence (MDC) as well as the distance to the UF-NFIND were calculated using ArcGIS 10.3. Results: A total of 5.2% (355/6867) of the sample population were identified as a Medicaid/self-pay population and classified as underserved. The most common diagnoses were tic disorder (19.2%), dystonia (18.3%), and Parkinson's disease (14.3%). In underserved persons, the median distances from their homes to the UF-NFIND (82.19 [45.79-176.93] km) vs. their nearest MDC (63.34 [26.91-121.43] km) were significantly different (p < 0.001). Discussion: Underserved persons in our study travelled further to receive subspecialty care at UF-NFIND than closer MDCs. Potential reasons for underutilization of closer care could possibly include research opportunities, availability of specific treatments or procedures, insurance restrictions, and limited specialist availability. Despite this observation, underserved persons were underrepresented at our institution compared to the proportion of Medicaid/uninsured patients in Florida. Our results highlight the need for increased awareness of care options for underserved movement disorders populations.

Reduced long-term cost and increased patient satisfaction with rechargeable implantable pulse generators for deep brain stimulation.

OBJECTIVE: Deep brain stimulation (DBS) has revolutionized the treatment of neurological disease, but its therapeutic efficacy is limited by the lifetime of the implantable pulse generator (IPG) batteries. At the end of the battery life, IPG replacement surgery is required. New IPGs with rechargeable batteries (RC-IPGs) have recently been introduced and allow for decreased reoperation rates for IPG replacements. The authors aimed to examine the merits and limitations of these devices. METHODS: The authors reviewed the medical records of patients who underwent DBS implantation at their institution. RC-IPGs were placed either during initial DBS implantation or during an IPG change. A cost analysis was performed that compared RC-IPGs with standard IPGs, and telephone patient surveys were conducted to assess patient satisfaction. RESULTS: The authors identified 206 consecutive patients from 2011 to 2016 who underwent RC-IPG placement (mean age 61 years; 67 women, 33%). Parkinson's disease was the most common indication for DBS (n = 144, 70%), followed by essential tremor (n = 41, 20%), dystonia (n = 13, 6%), depression (n = 5, 2%), multiple sclerosis tremor (n = 2, 1%), and epilepsy (n = 1, 0.5%). DBS leads were typically placed bilaterally (n = 192, 93%) and targeted the subthalamic nucleus (n = 136, 66%), ventral intermediate nucleus of the thalamus (n = 43, 21%), internal globus pallidus (n = 21, 10%), ventral striatum (n = 5, 2%), or anterior nucleus of the thalamus (n = 1, 0.5%). RC-IPGs were inserted at initial DBS implantation in 123 patients (60%), while 83 patients (40%) were converted to RC-IPGs during an IPG replacement surgery. The authors found that RC-IPG implantation resulted in $60,900 of cost savings over the course of 9 years. Furthermore, patient satisfaction was high with RC-IPG implantation. Overall, 87.3% of patients who responded to the survey were satisfied with their device, and only 6.7% found the rechargeable component difficult to use. In patients who were switched from a standard IPG to RC-IPG, the majority who responded (70.3%) preferred the rechargeable IPG. CONCLUSIONS: RC-IPGs can provide DBS patients with long-term therapeutic benefit while minimizing the need for battery replacement surgery. The authors have implanted rechargeable stimulators in 206 patients undergoing DBS surgery, and here they demonstrate the cost-effectiveness and high patient satisfaction associated with this procedure.

Telemedicine Use for Movement Disorders: A Global Survey.

BACKGROUND: Telemedicine is increasingly used to care for patients with movement disorders, but data regarding its global use are limited. INTRODUCTION: To obtain baseline international data about telemedicine use among movement disorder clinicians. METHODS: An online survey was sent to all 6,056 Movement Disorder Society members in 2015. Scope, reimbursement, and perceived quality of telemedicine were assessed. RESULTS: There were 549 respondents (9.1% overall response rate) from 83 countries. Most (85.8%) were physicians, and most (70.9%) worked in an academic or university practice. Half of respondents (n = 287, from 57 countries) used telemedicine for clinical care; activities included e-mail (63.2%), video visits (follow-up [39.7%] and new [35.2%]), and video-based education (35.2%). One hundred five respondents personally conducted video visits, most frequently to outpatient clinics (53.5%), patient homes (30.8%), and hospital inpatients (30.3%). The most common challenges were a limited neurological examination (58.9%) and technological difficulties (53.3%), and the most common benefits were reduced travel time (92.9%) and patient costs (60.1%). The most frequent reimbursements were none (39.0%), public insurance (24.5%), and patient payment (9.3%). Half of respondents planned to use telemedicine in the future, and three-quarters were interested in telemedicine education. CONCLUSIONS: More than 250 respondents around the world engage in telemedicine for movement disorders; most perceived benefit for patients, despite challenges and reimbursement for clinicians. Formal instruction on telemedicine is highly desired. Although the survey response was low and possibly biased to over represent those with telemedicine experience, the study provides baseline data for future comparison and to improve telemedicine delivery.

Toe walking: causes, epidemiology, assessment, and treatment.

PURPOSE OF REVIEW: The present review includes the most up-to-date literature on the causes, epidemiology, diagnosis, and treatment of toe walking. RECENT FINDINGS: The prevalence of toe walking at age 5.5 years is 2% in normally developing children, and 41% in children with a neuropsychiatric diagnosis or developmental delays. A recent systematic review concluded that there is good evidence for casting and surgery in the treatment of idiopathic toe walking, with only surgery providing long-term results beyond 1 year. Botox combined with casting does not provide better outcomes compared with casting alone. Ankle-foot-orthoses restrict toe walking when worn, but children revert to equinus gait once the orthosis is removed. SUMMARY: Toe walking can occur because of an underlying anatomic or neuromuscular condition, but in the majority of cases toe walking is idiopathic, without a discernable underlying cause. For some families, toe walking may simply be a cosmetic concern, whereas in other cases it can cause pain or functional issues. Treatment for toe walking is based on age, underlying cause, and the severity of tendon contracture. Described treatments include casting, chemical denervation, orthotics, physical therapy, and surgical lengthening of the gastroc-soleus-Achilles complex. A careful history, clinical exam, and selective diagnostic testing can be used to differentiate between different types of toe walking and determine the most appropriate treatment for each child.

A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders.

Remote assessments of individuals with a neurological disease via telemedicine have the potential to reduce some of the burdens associated with clinical care and research participation. We aim to evaluate the feasibility of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. A pilot study derived from two telemedicine trials was conducted. In total, 17 individuals with movement disorders (8 with Parkinson disease and 9 with Huntington disease) had Montreal Cognitive Assessment examinations evaluated in-person and remotely via web-based video conferencing to primarily determine feasibility and potential barriers in its remote administration. Administering the Montreal Cognitive Assessment remotely in a sample of movement disorder patients with mild cognitive impairment is feasible, with only minor common complications associated with technology, including delayed sound and corrupted imaging for participants with low connection speeds. The Montreal Cognitive Assessment has the potential to be used in remote assessments of patients and research participants with movement disorders.

Risks of common complications in deep brain stimulation surgery: management and avoidance.

OBJECT: Deep brain stimulation (DBS) surgery is increasingly prominent in the treatment of various disorders refractory to medication. Despite the procedure's efficacy, the community at large continues to be hesitant about presumed associated risks. The main object of this study was to assess the incidence of various surgical complications occurring both during and after DBS device implantation in a large population of patients with movement disorders in an effort to better quantify patient risk, define management plans, and develop methods for risk avoidance. A second aim was to corroborate the low procedural complication risk of DBS reported by others, which in light of the procedure's efficacy is needed to promote its widespread acceptance. METHODS: All patients who had undergone new DBS device implantation surgery between 2002 and 2010 by a single surgeon were entered into a database after being verified by cross-referencing manufacturer implantation records. All surgical records and charts were reviewed to identify intraoperative, perioperative, and long-term surgical complications, including any characteristics predictive of an adverse event. RESULTS: Seven hundred twenty-eight patients received 1333 new DBS electrodes and 1218 new internal pulse generators (IPGs) in a total of 1356 stereotactic procedures for the treatment of movement disorders. Seventy-eight percent of the patients had staged lead and IPG implantations. Of the 728 patients, 452 suffered from medically refractory Parkinson disease; in the other patients, essential tremor (144), dystonia (64), mixed disease (30), and other hyperkinetic movement disorders (38) were diagnosed. Severe intraoperative adverse events included vasovagal response in 6 patients (0.8%), hypotension in 2 (0.3%), and seizure in 2 (0.3%). Postoperative imaging confirmed asymptomatic intracerebral hemorrhage (ICH) in 4 patients (0.5%), asymptomatic intraventricular hemorrhage in 25 (3.4%), symptomatic ICH in 8 (1.1%), and ischemic infarction in 3 (0.4%), associated with hemiparesis and/or decreased consciousness in 13 (1.7%). Long-term complications of DBS device implantation not requiring additional surgery included hardware discomfort in 8 patients (1.1%) and loss of desired effect in 10 (1.4%). Hardware-related complications requiring surgical revision included wound infections in 13 patients (1.7%), lead malposition and/or migration in 13 (1.7%), component fracture in 10 (1.4%), component malfunction in 4 (0.5%), and loss of effect in 19 (2.6%). CONCLUSIONS: The authors confirmed that the overall risk of both procedure- and hardware-related adverse events is acceptably low. They offer advice on how to avoid the most common complications.

Future of brain stimulation: new targets, new indications, new technology.

In the last quarter of a century, DBS has become an established neurosurgical treatment for Parkinson's disease (PD), dystonia, and tremors. Improved understanding of brain circuitries and their involvement in various neurological and psychiatric illnesses, coupled with the safety of DBS and its exquisite role as a tool for ethical study of the human brain, have unlocked new opportunities for this technology, both for future therapies and in research. Serendipitous discoveries and advances in structural and functional imaging are providing abundant "new" brain targets for an ever-increasing number of pathologies, leading to investigations of DBS in diverse neurological, psychiatric, behavioral, and cognitive conditions. Trials and "proof of concept" studies of DBS are underway in pain, epilepsy, tinnitus, OCD, depression, and Gilles de la Tourette syndrome, as well as in eating disorders, addiction, cognitive decline, consciousness, and autonomic states. In parallel, ongoing technological development will provide pulse generators with longer battery longevity, segmental electrode designs allowing a current steering, and the possibility to deliver "on-demand" stimulation based on closed-loop concepts. The future of brain stimulation is certainly promising, especially for movement disorders-that will remain the main indication for DBS for the foreseeable future-and probably for some psychiatric disorders. However, brain stimulation as a technique may be at risk of gliding down a slippery slope: Some reports indicate a disturbing trend with suggestions that future DBS may be proposed for enhancement of memory in healthy people, or as a tool for "treatment" of "antisocial behavior" and for improving "morality."

Complementary therapies in hemifacial spasm and comparison with other movement disorders.

OBJECTIVES: We determined the prevalence, range and factors influencing the use of complementary therapy among hemifacial spasm patients and compared the patterns of use of complementary therapies across different movement disorders in a systematic pooled analysis of published literature. METHODS: A structured questionnaire was administered to 96 hemifacial spasm patients evaluating frequency of complementary therapy use, and factors influencing patients' decision to seek these therapies. We also performed a PubMed search of epidemiology studies on use of complementary therapies in movement disorders. RESULTS: Fifty-one per cent of patients had tried complementary therapies, of which 47% reported some perceived benefit and 4.1% informed their doctor. Acupuncture (71.4%) and facial massage (17.6%) were most commonly used. Complementary therapy use was associated with greater HFS severity. The mean cost of treatment was about $78 per month. We identified eight articles on use of complementary therapies in movement disorders; Parkinson's disease (5), Tourette syndrome (2) and dystonia (1). Twenty-five to 88% of patient had tried complementary therapies, of which 32-70% reported some benefit. Trials of acupuncture (2-63%) and massage (7-38%) were reported across the spectrum of movement disorders studied. Mean cost of complementary therapies varied from 43 to 102 USD per month. CONCLUSION: Complementary therapies are used by over 50% of HFS patients, and the use is correlated with severity of disease. Despite differences in race, culture and population demographics, acupuncture and massage are used by patients across the spectrum of movement disorders.

[Tardive dyskinesia: diagnosis, assessment and treatment]. / Discinesia tardiva: diagnosi, valutazione e terapia.

Tardive dyskinesia is a potentially fatal side effect of antipsychotics. In the classic form is characterized by involuntary hyperkinetic movements, especially those affecting the mimic and mastication muscles. The main hypothesis considers that the pathophysiological basis of the disorder is an overexpression of D2 receptors in the striatum, in response to dopamine block neuroleptics-mediated, especially the older ones. Because fortunately not all patients undergo this severe adverse effects, many efforts have been conducted in trying to delineate the risk factors so as to try to prevent tardive dyskinesia by administering lower doses of neuroleptics in vulnerable groups. Advanced age, female sex, smoking habits, diabetes mellitus, alcohol abuse are known as risk factors. The instead the role of the type of psychiatric disorder, instead, is still debated. Since there was a direct relationship between cumulative dose of antipsychotic and treatment duration, recent studies are aimed at identifying factors that contribute to increased plasma concentrations of the drug, such as genetic polymorphisms of metabolizer enzymes that encode for enzymatic variants with decreased activity.

A quantitative assessment of the accuracy and reliability of O-arm images for deep brain stimulation surgery.

BACKGROUND: Deep brain stimulation (DBS) surgery has an average accuracy of 2 to 3 mm (range, 0-6 mm). Intraoperative detection of track location may be useful in interpreting physiological results and thus limit the number of brain penetrations as well as decrease the incidence of reoperations. The O-arm has been used to identify the DBS lead position; however, early results have indicated a significant discrepancy with lead position on postoperative imaging. OBJECTIVE: This prospective study was conducted to determine the accuracy and reliability of fiducial and track localization and to assess the accuracy of O-arm image-based registration. The computed tomography (CT) image was considered the gold standard, and so for this study, the locations of all objects on the O-arm image were compared with their CT location. METHODS: Thirty-three DBS surgeries were performed using the O-arm to image each track with detailed analysis of fiducial and track localization accuracy. Twenty-one subsequent surgeries were performed using O-arm registration. Only the final lead position was assessed in these individuals. RESULTS: The measurement error of the system was 0.7 mm, with a maximum error of 1.9 mm. Twenty-two percent of the parallel tracks through the BenGun exceeded this error and demonstrated the ability of the O-arm to detect these skewed tracks. The accuracy of final lead position was 2.04 mm in procedures with registration based on an O-arm image. This was not significantly different from CT-based registration at 2.16 mm. CONCLUSION: The O-arm was able to detect skewed tracks and provide registration accuracy equivalent to a CT scan.

Quality care assessment of Parkinson's disease at a tertiary medical center.

The purpose of this study was to determine the level of care of Parkinson's disease patients based on the 10 American Academy of Neurology quality measures. We reviewed 1,367 charts and final analysis was completed on 123 subjects. A total of 1,461 outpatient neurology visits from 33 neurologists were reviewed and 544 were included in the final analysis. Out of all 10 quality measures (13 individual questions addressed), "annual review of Parkinson's medications" was the most frequently documented (97.2%) and "annual review of safety issues appropriate to the patient's stage of disease" was the least frequently documented item (7.2%). Movement disorders specialists recorded significantly more items than other neurologists (4.7 ± 2.86 vs 3.3 ± 1.97, p = .0437); the provider with the highest number of items addressed was a movement disorders nurse practitioner (8.22 out of 13). None of the patient characteristics influenced the rates of documentation of the 10 quality measures. The wide variation of documentation rates could be addressed by comprehensive standardized templates to be reviewed and updated at each visit.

New horizons in the pathogenesis, assessment and management of movement disorders.

In this review, we shall outline recent advances in our understanding of the movement disorders which geriatricians encounter in their clinical practice. Many of these diseases are no longer simply considered disorders of movement: carefully conducted longitudinal studies have shown that concomitant cognitive dysfunction, neuropsychiatric disturbance and behavioural issues are frequent and exert a heavy burden on the individual and their carers. Great progress has been made in understanding the molecular and cellular processes that drive the pathological changes in these conditions, as have advances in neuroimaging and preclinical drug discovery programmes. Unfortunately, this is yet to translate into disease-modifying therapies for these progressive disorders. Advances have been also made in non-pharmacological interventions such as tailored physiotherapy and speech therapy programmes. The important contribution of palliative care has been recognised and increasingly incorporated into the multidisciplinary approach. The UK is at the forefront of research into these conditions and geriatricians are well placed to contribute to research through recruiting patients to observational studies or therapeutic trials, particularly with the support of agencies such as the National Institute for Health Research-Dementias & Neurodegenerative Diseases Research Network (NIHR-DeNDRoN).

Pharmacist's role in a Parkinson's disease and movement disorders clinic.

PURPOSE: The expanding role of a clinical pharmacist at a Veterans Affairs (VA) out-patient clinic for patients with Parkinson's disease (PD) and movement disorders is described. SUMMARY: San Francisco VA Medical Center added a clinical pharmacist to the multi-disciplinary team serving patients at an outpatient clinic operated by its Parkinson's Disease Research, Education and Clinical Center (PADRECC). During the first six months after joining the clinic team, the pharmacist met with 131 patients and made a total of 69 drug therapy recommendations that were implemented by neurologists, clinical nurse specialists, and other PADRECC providers. The results of a retrospective chart review suggested that in about 21% of the cases evaluated, the pharmacist's recommendations contributed to an improved medical outcome or the resolution of a medical problem. Anonymous surveys indicated that clinic providers (n = 33) and patients (n = 20) were satisfied with the pharmacist's services. Using a five-point Likert scale (scores ranged from 1 for "strongly disagree" to 5 for "strongly agree") that they had more time to devote to other clinic responsibilities with the pharmacist present in the clinic (mean score, 4.79); patients indicated that they had an improved understanding of their medications after speaking with the pharmacist (mean score, 4.88). CONCLUSION: A clinical pharmacist's regular involvement in an outpatient PD and movement disorders clinic has been well received by patients and clinic providers. The study results suggest that the pharmacist has made important contributions in areas such as therapeutic problem solving and medication education while freeing up providers for other responsibilities.

[Perioperative management of Parkinson's disease]. / Manejo perioperatorio de la enfermedad de Parkinson.

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

Diferenças regionais e custos dos procedimentos de fisioterapia no Sistema Único de Saúde do Brasil, 1995 a 2008 / Regional differences and costs of physical therapy procedures in Brazil's Unified Health System, 1995 to 2008

OBJETIVO: Descrever os atendimentos ambulatoriais fisioterßpicos prestados pelo Sistema Único de Saúde (SUS) no Brasil quanto a sua distribuição geogrßfica, custos, tipos de procedimento e tipos de prestador. MÉTODOS: Foram utilizados dados do Departamento de Informßtica do SUS (DATASUS), referentes ao período de 1995 a 2008, que incluíam a quantidade e o valor dos procedimentos aprovados para pagamento pelas Secretarias de Saúde e a quantidade e o valor dos procedimentos apresentados para pagamento. Os coeficientes de atendimento (CoA) foram calculados dividindo-se o número de atendimentos no ano em uma região pela população estimada no mesmo ano e região. RESULTADOS: O CoA no Brasil em 2008 foi de 0,19 e as regiões Norte e Centro-Oeste apresentaram os menores coeficientes (0,13 e 0,10, respectivamente). Entre 1995 e 2007 houve um crescimento no coeficiente nacional de atendimentos de 33,7 por cento, sendo que a região Norte apresentou o maior aumento, de 143,8 por cento, a Centro-Oeste, de 62,1 por cento, e a Nordeste, de 56,1 por cento. O atendimento nas alterações motoras foi o procedimento mais realizado (61,8 por cento) e os valores de pagamento aprovados foram menores que os apresentados pelos gestores dos serviços em 2008 (10,4 por cento). Estabelecimentos privados com fins lucrativos prestaram 44,5 por cento dos atendimentos fisioterßpicos pagos pelo SUS em 2008. Os estabelecimentos municipais responderam por 26,6 por cento dos atendimentos e os federais por apenas 0,9 por cento. Entre 1995 e 2007, a quantidade de atendimentos oferecidos pelos estabelecimentos municipais cresceu 278,7 por cento. CONCLUSÕES: Observou-se que a oferta de atendimento fisioterßpico ambulatorial pelo SUS ainda é pequena e geograficamente desigual, embora regiões menos desenvolvidas apresentem um maior crescimento no CoA. O SUS remunera inadequadamente os serviços prestados em fisioterapia e ainda o faz, em grande parte, por meio de convênios...

OBJECTIVE: Describe the ambulatory physical therapy treatments provided by the Unified Health System (SUS) in Brazil with regard to their geographical distribution, costs, types of procedure, and types of provider. METHODS: Data from the SUS Information Technology Department (DATASUS) were utilized, drawing from the period from 1995 to 2008, which included the quantity and the value of the procedures approved for payment by the Secretariats of Health and the quantity and value of the procedures presented for payment. The treatment coefficients (CoA) were calculated by dividing the number of treatments in a particular year and region by the estimated population of that region in that year. RESULTS: The CoA in Brazil in 2008 was 0.19 and the North and Center-West regions presented the lowest coefficients (0.13 and 0.10, respectively). Between 1995 and 2007 there was an increase in the national treatment coefficient of 33.7 percent, with the North region showing the largest increase, 143.8 percent; the Center-West 62.1 percent, and the Northeast 56.1 percent. Treatment for motor disorders was the most widely performed procedure (61.8 percent), and the values of payments approved were lower than those presented by the managers of the services in 2008 (10.4 percent). Private for-profit establishments provided 44.5 percent of the physical therapy treatments paid for by the SUS in 2008. Municipal establishments accounted for 26.6 percent of the treatments, and federal establishments for only 0.9 percent. Between 1995 and 2007, the quantity of treatments offered by municipal establishments increased 278.7 percent. CONCLUSIONS: It was observed that the provision of ambulatory physical therapy treatment by the SUS remains small and geographically unequal, although lessdeveloped regions showed a larger increase in the CoA. The SUS remunerates inadequately the physical therapy services provided and continues to do so, in large part, by means of agreements...