based practice.
Keus, S.H.J.
Citation
Keus, S. H. J. (2010, April 29). Physiotherapy in Parkinson's disease. towards evidence-based practice. Retrieved from https://hdl.handle.net/1887/15341
Version: Corrected Publisher’s Version
License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden
Downloaded from: https://hdl.handle.net/1887/15341
Note: To cite this publication please use the final published version (if applicable).
*HQHUDOGLVFXVVLRQDQGIXWXUHFKDOOHQJHV
*HQHUDOGLVFXVVLRQDQGIXWXUH
FKDOOHQJHV
%DVHGRQ .HXV6+-0XQQHNH01LMNUDNH0-.ZDNNHO*DQG%ORHP%50RY'LVRUG
6XPPDU\
6LJQLÀFDQWPLOHVWRQHVLQWKHTXDOLW\RIVWXGLHVKDYHEHHQUHDFKHGEXWPDQ\PRUHJRDOV
UHPDLQ:KHQVWULYLQJWRUHDFKWKHVHJRDOVIRXULPSRUWDQWLVVXHVVKRXOGEHWDNHQLQWR
DFFRXQW)LUVWVWXG\GHVLJQVVKRXOGEHLPSURYHG HJSURSHUUDQGRPLVDWLRQ VXSSRUW
VXIÀFLHQWUHFUXLWPHQW6HFRQGLQVLJKWVLQWKHRSWLPDOGHOLYHU\RI SK\VLRWKHUDS\LQWHU
YHQWLRQVRYHUWLPHVKRXOGEHJDLQHG7KLUGDSSURSULDWHRXWFRPHPHDVXUHVWDLORUHGWR
WKHSDWLHQWVDQGLQWHUYHQWLRQVWXGLHGVKRXOGEHFKRVHQ)RXUWKDOOQHZWULDOVVKRXOGEH
UHJLVWHUHGLQDGDWDEDVHIRUFOLQLFDOWULDOVEHIRUHWKHVWDUWRI SDWLHQWLQFOXVLRQDQGVKRXOG
EHSXEOLVKHGDFFRUGLQJWRWKH&216257VWDWHPHQW
$WWKHVDPHWLPHVXVWDLQHGDWWHQWLRQQHHGVWREHJLYHQWRLPSOHPHQWDQ\QHZDFTXLUHG
HYLGHQFHLQWRFOLQLFDOFDUH2QHRSWLRQIRUWKLVLVWKHGHYHORSPHQWRIFRPPXQLW\EDVHG
QHWZRUNVRI GHGLFDWHGKHDOWKSURIHVVLRQDOVVSHFLDOLVHGLQ3' HJ3DUNLQVRQ1HWLQWKH
1HWKHUODQGV&KDSWHU *LYHQWKHFRPSOH[QDWXUHRI3'WKHVHQHWZRUNVVKRXOGEH
PXOWLGLVFLSOLQDU\7KHUHFHQWO\GHYHORSHG'XWFKQDWLRQDOPXOWLGLVFLSOLQDU\JXLGHOLQHIRU
3'SURYLGHVUHFRPPHQGDWLRQVWRPHHWWKHUHTXLUHPHQWVIRUWKHRSWLPDORUJDQLVDWLRQRI PXOWLGLVFLSOLQDU\FDUH7KHVHUHTXLUHPHQWVLQFOXGHDQDGHTXDWHOHYHORI H[SHUWLVHJRRG
FRPPXQLFDWLRQDQGLQWHUGLVFLSOLQDU\FROODERUDWLRQFOHDUFRRUGLQDWLRQRI FDUHDQGVROLG
ÀQDQFLDOXQGHUSLQQLQJ:KHQWKHUHFRPPHQGDWLRQVDUHIROORZHGXSDQGUHIHUUDOLVVWUXF
WXUHGWRWKHUDSLVWVZLWK3'VSHFLÀFH[SHUWLVHHYLGHQFHEDVHGFDUHPD\EHDFKLHYHG
*HQHUDOGLVFXVVLRQDQGIXWXUHFKDOOHQJHV
,QWURGXFWLRQ
7KLVWKHVLVKDVSURYLGHGLQVLJKWLQWRWKHXVHDQGDGGHGYDOXHRISK\VLRWKHUDS\LQ3'DV
VXFKUHSUHVHQWVDVWHSIRUZDUGLQWKHGHYHORSPHQWRIHYLGHQFHEDVHGSK\VLRWKHUDS\IRU
SDWLHQWVZLWK3'$OWKRXJKWKHTXDOLW\DQGTXDQWLW\RIHYLGHQFHIRUSK\VLRWKHUDS\LQ3'
LVJURZLQJPRUHVXSSRUWLYHHYLGHQFHRIKLJKTXDOLW\UHPDLQVUHTXLUHG0RUHRYHUVXV
WDLQHGDWWHQWLRQQHHGVWREHJLYHQWRLPSOHPHQWDQ\QHZO\DFTXLUHGHYLGHQFHLQWRFOLQLFDO
FDUH6RPHRI WKHIXWXUHFKDOOHQJHVERWKIRUUHVHDUFKDQGIRUWKHLPSOHPHQWDWLRQRI HYLGHQFHLQWRFDUHZLOOEHGLVFXVVHGEULHÁ\EHORZ
2SWLPLVLQJVWXG\TXDOLW\
4XDOLW\DVVHVVPHQWVWKDWZHUHGRQHDVSDUWRIWKHV\VWHPDWLFUHYLHZVVKRZHGWKDWPDQ\
SXEOLVKHGWULDOVKDGVHULRXVPHWKRGRORJLFDOOLPLWDWLRQVOHDGLQJWRXQMXVWLÀHGFRQFOXVLRQV
DERXWWKHHIÀFDF\ &KDSWHUVDQG %LDVLQVWXG\GHVLJQDQGWKHFRPPRQSUDFWLFH
RI XVLQJPXOWLSOHRXWFRPHPHDVXUHVODFNRI DVVHVVRUEOLQGLQJRULQDGHTXDWHSODFHER
HJQRWUHFHLYLQJDQ\DWWHQWLRQ PLJKWKDYHSURYLGHGIDOVHSRVLWLYHUHVXOWV 2QWKHRWKHUKDQGIDOVHQHJDWLYHUHVXOWVPD\KDYHUHVXOWHGIURPXVHRILQDSSURSULDWH
RXWFRPHPHDVXUHV LHZLWKRXWSDUWLFXODUUHOHYDQFHWRSDWLHQWVFDUHUVRUSK\VLRWKHUDSLVWV
RUZLWKRXWSURYHQUHVSRQVLYHQHVV ODFNRI SRZHUDQGLQVXIÀFLHQWFRQWUDVWEHWZHHQH[
SHULPHQWDODQGFRQWUROJURXSV ,QDGGLWLRQDZLGHYDULHW\RI RXWFRPHPHDVXUHV
LVFXUUHQWO\EHLQJXVHG,QWKHLUUHFHQWUHYLHZ.ZDNNHOHWDOUHSRUWHGWKHXVHRIGLI
IHUHQWRXWFRPHPHDVXUHVWRHYDOXDWHDFWLYLWLHVRIGDLOW\OLYLQJ $'/ DIWHUSK\VLRWKHUDS\
LQ3'7KLVLQFRQVLVWHQF\LQRXWFRPHPHDVXUHVSUHFOXGHVJRRGFRPSDULVRQRI VWXG\
UHVXOWVDQGSURKLELWVSRROLQJRI GDWD
)XWXUHVWXGLHVDUHQHHGHGWRIXUWKHUXQGHUSLQDQ\UHFRPPHQGDWLRQVIRUHYHU\GD\FOLQLFDO
SUDFWLFHDQGWRLQFUHDVHWKHOHYHOVRIVXSSRUWLQJHYLGHQFH/LPLWDWLRQVRI WULDOVFRP
SOHWHGVRIDUSURYLGHOHVVRQVIRURSWLPL]LQJWKHGHVLJQRIIXWXUHWULDOV6HYHUDOVLJQLÀFDQW
PLOHVWRQHVLQWKHTXDOLW\RIVWXGLHVKDYHEHHQUHDFKHGEXWPDQ\PRUHJRDOVUHPDLQ
)RXULPSRUWDQWLVVXHVVKRXOGEHWDNHQLQWRDFFRXQW GHVLJQDQGUHFUXLWPHQW GHOL
YHU\RISK\VLRWKHUDS\ RXWFRPHPHDVXUHV DQG SXEOLFDWLRQ:HZLOOEULHÁ\GLVFXVV
WKHVHEHORZ
'HVLJQDQGUHFUXLWPHQW
7KHPRVWLPSRUWDQWOLPLWDWLRQVLQVWXG\GHVLJQWKDWQHHGWREHWDFNOHGLQIXWXUHVWXGLHV
DUHSURSHUUDQGRPLVDWLRQRI WUHDWPHQWDUPVZLWKDFRQFHDOHGDOORFDWLRQDQGEOLQGLQJ
RI SDWLHQWV %OLQGLQJRI WKHUDSLVWVLVDOVRRIWHQQHJOHFWHGEXWWKLVFDQRQO\EH
DYRLGHGZKHQWZRLQWHUYHQWLRQVDUHFRPSDUHGNHHSLQJWKHWKHUDSLVWVXQDZDUHRI WKH
SUHIHUUHGLQWHUYHQWLRQ)XUWKHUPRUHPRVWSULRUVWXGLHVZHUHXQGHUSRZHUHG$OWKRXJK
ODUJH Q HYHQWKHVWXG\E\$VKEXUQHWDOZDVXQGHUSRZHUHGIRUWKHLUJRDOV LH
IDOOVSUHYHQWLRQ )XWXUHVWXGLHVVKRXOGWKHUHIRUHLQFOXGHVXIÀFLHQWQXPEHUVRI SDWLHQWVEDVHGRQSRZHUDQDO\VHVWDLORUHGWRWKHSULPDU\UHVHDUFKTXHVWLRQDQGDVLQJOH
SULPDU\RXWFRPHPHDVXUH$VSHFLÀFFKDOOHQJHKHUHLVWKHGLIÀFXOW\LQUHFUXLWLQJVXI
ÀFLHQWSDWLHQWVLQDQUDQGRPLVHGFRQWUROOHGWULDO 5&7 RI SK\VLRWKHUDS\LQ3' )RUH[DPSOHLQDVWXG\ZLWKUDQGRPLVDWLRQEHWZHHQ¶PHGLFDOWUHDWPHQWZLWKDGGLWLRQDO
SK\VLRWKHUDS\·FRPSDUHGZLWK¶PHGLFDOWUHDWPHQWZLWKRXWDGGLWLRQDOSK\VLRWKHUDS\·
OHVVWKDQRIHOLJLEOHSDWLHQWVZDVZLOOLQJWRSDUWLFLSDWH7KHPDLQUHDVRQIRUQRW
ZLOOLQJWRSDUWLFLSDWHZDVWKDWSDWLHQWVZHUHDOUHDG\UHFHLYLQJSK\VLRWKHUDS\ RIWHQDV
PDLQWHQDQFHWKHUDS\ DQGZHUHXQZLOOLQJWREHUDQGRPO\DOORFDWHGZLWKDFKDQFHWR
WKH¶QRSK\VLRWKHUDS\·DUP7KLVUHFUXLWPHQWSUREOHPPLJKWOHDGWRDVHOHFWLRQELDVDQG
SUHFOXGHVDXWRPDWLFJHQHUDOLVDWLRQRI WKHÀQGLQJVWRWKHRYHUDOO3'SRSXODWLRQ
)XWXUH5&7VFDQEHQHÀWIURPWKLVNQRZOHGJHDQGDYRLGWKHUHFUXLWPHQWSUREOHPHJ
E\XVLQJDUDQGRPLVHGFURVVRYHUGHVLJQRUDFOXVWHUUDQGRPLVHGGHVLJQLQZKLFKQRWSD
WLHQWVDUHUDQGRPLVHGEXWIRUH[DPSOHWKHUDSLVWV,QDGGLWLRQWRUHGXFHWKHZLWKLQVXE
MHFWYDULDELOLW\ PDLQO\LQWURGXFHGE\WLPHGHSHQGHQWÁXFWXDWLRQVLQOHYRGRSDPHGLFDWLRQ
XVHLQSDWLHQWVZLWK3' 5&7VZLWKDUHSHDWHGPHDVXUHPHQWGHVLJQDUHDGYRFDWHGIRU
IXWXUHWULDOV,QWKHÀUVW5&7ZLWKDVXIÀFLHQWQXPEHURI SDWLHQWVZDVSXEOLVKHG
7KLVVRFDOOHG5(6&8(VWXG\HQWDLOHGDFURVVRYHUVWXG\FDUULHGRXWWKURXJKLQWHUQD
WLRQDOFROODERUDWLRQEHWZHHQWKUHHXQLYHUVLW\PHGLFDOFHQWUHV $PVWHUGDP1HZFDVWOHDQG
/HXYHQ $VVXFKWKLVZDVDEHQFKPDUNVWXG\LQWKHÀHOG$ÀUVWH[DPSOHRI DFOXVWHU
5&7LVWKH'XWFK3DUNLQVRQ1HW7ULDOWKDWZDVUHFHQWO\FRPSOHWHG%HVLGHVRYHUFRPLQJ
SUREOHPVLQUHFUXLWPHQWWKLVGHVLJQDOVRRIIHUVWKHSRVVLELOLW\WREOLQGSDWLHQWVIRUWKH
LQWHUYHQWLRQDUPUHFHLYHG
:KHQFKRRVLQJDFURVVRYHUGHVLJQDVXIÀFLHQWWLPHVSDQEHWZHHQWKHWZRUHVHDUFK
SHULRGVLVFUXFLDOLQRUGHUWRDYRLGDFDUU\RYHURI ORQJWHUPWUHDWPHQWHIIHFWVLQWRWKH
QH[WWUHDWPHQWSHULRG:KHQFKRRVLQJDFOXVWHU5&7DVXIÀFLHQWFRQWUDVWEHWZHHQFRQ
WURODQGH[SHULPHQWDOFOXVWHUVQHHGVWREHZDUUDQWHG(VSHFLDOO\ZKHQFRQWUROFOXVWHUVDUH
SURYLGLQJ¶XVXDOFDUH·WKLVLVDPDMRUFRQFHUQ
)LQDOO\DOLPLWDWLRQLQSULRUUHVHDUFKGHVLJQVZDVWKHSHULRGRI IROORZXSZKLFKZDV
RIWHQDEVHQWRURQO\EULHI OHVVWKDQIRXUZHHNV $OWKRXJKPRVWRQJRLQJVWXGLHV
DUHQRZXVLQJDPXFKORQJHUIROORZXSPDQ\VWXGLHVVWLOOIDLOWRUHDFKWKHUHFRPPHQGHG
PLQLPDOIROORZXSSHULRGRIVL[PRQWKV &KDSWHU
'HOLYHU\RI SK\VLRWKHUDS\
([SHULHQFHLQWKHÀHOGRIVWURNHLQGLFDWHVWKDWWUDLQLQJHIIHFWVKLJKO\GHSHQGRQWKH
LQWHQVLW\RISK\VLRWKHUDS\ERWKLQWHUPVRI IUHTXHQF\DQGGXUDWLRQRI WUHDWPHQW +RZHYHUSULRUVWXGLHVLQ3'KDUGO\SURYLGHLQVLJKWVLQWRWKHRSWLPDOWUHDWPHQWIUHTXHQ
*HQHUDOGLVFXVVLRQDQGIXWXUHFKDOOHQJHV F\DQGGXUDWLRQRI WKHUDS\$FKDOOHQJHLVSRVHGE\WKHSURJUHVVLYHQDWXUHRI 3'ZKLFK
OHDGVWRLQFUHDVLQJOLPLWDWLRQV$VDFRQVHTXHQFHDQ\LPSURYHPHQWVIROORZLQJLQWHUYHQ
WLRQPD\GHWHULRUDWHDJDLQZLWKWLPH7KHUHIRUHZHQHHGWRJDLQPXFKEHWWHULQVLJKWVDLQ
WKHRSWLPDOGHOLYHU\RILQWHUYHQWLRQVRYHUWLPH
2XWFRPHPHDVXUHV
0RVWVWXGLHVODFNDSSURSULDWHSULPDU\RXWFRPHPHDVXUHVWKDWFDQPHDVXUHFOLQLFDOO\UHO
HYDQWFKDQJHVDIIRUGHGE\SK\VLRWKHUDS\7KHUHDUHVHYHUDOSUREOHPV)LUVWPDQ\VWXGLHV
VHOHFWHGPXOWLSOH¶SULPDU\·RXWFRPHPHDVXUHVWKHUHE\LQFUHDVLQJWKHSUREDELOLW\RI ÀQ
GLQJSRVLWLYHUHVXOWVE\DFFLGHQW7KLVVWUDWHJ\LVWRVRPHH[WHQWXQGHUVWDQGDEOHEHFXDVH
WKHZLGHUDQJHRISUREOHPVW\SLFDOO\H[SHULHQFHGE\HDFKLQGLYLGXDOSDWLHQWPDNHVLW
GLIÀFXOWWRFKRRVHMXVWRQHRXWFRPHPHDVXUHNQRZLQJWKDWWKLVZLOOOLNHO\QRWFDSWXUHDOO
DLPVRI DPXOWLIDFHWHGSK\VLRWKHUDS\LQWHUYHQWLRQ%XWLQUHDOLW\WKHUHFDQEHRIFRXUVH
²E\GHÀQLWLRQ²RQO\RQHSULPDU\RXWFRPHPHDVXUHDQGWKLVQHHGVWREHGHÀQHGSULRU
WRRQVHWRIWKHWULDO6HFRQGWKHVHOHFWHGRXWFRPHPHDVXUHVZHUHQRWDOZD\VWDLORUHG
WRWKHJRDO LHWKHHIÀFDF\RISK\VLRWKHUDS\LQ3' DQGZHUHWKHUHIRUHLQVXIÀFLHQWO\
UHVSRQVLYHWRFKDQJH0RVWRI WKHDSSOLHGRXWFRPHPHDVXUHVKDYHEHHQGHYHORSHGIRU
RWKHUJRDOVWKDQHYDOXDWLQJWKHHIÀFDF\RISK\VLRWKHUDS\LQ3')RUH[DPSOHPRVWLWHPV
RI WKHZLGHO\XVHG83'56FRQFHUQLPSDLUPHQWV HJULJLGLW\DQGOHJDJLOLW\LQWKH0RWRU
6HFWLRQ RUDFWLYLWLHVZKLFKZLOOQRWLPSURYHZLWKSK\VLRWKHUDS\ HJVSHHFKDQGVZDOORZ
LQJLQWKH$'/6HFWLRQ DQGDUHWKHUHIRUHQRWOLNHO\WRGHWHFWFKDQJH
,QIXWXUHWULDOVSULPDU\RXWFRPHPHDVXUHVVKRXOGEHVHOHFWHGWKDWDUHUHVSRQVLYHDQG
WKDWPDWFKWKHDLPVRIWKHLQWHUYHQWLRQVWXGLHG&RQVHQVXVQHHGVWREHUHDFKHGDERXW
ZKLFKRXWFRPHPHDVXUHVFDQEHDSSOLHGLQIXWXUHWULDOV7KH2XWFRPH0HDVXUHLQ
5KHXPDWRORJ\ 20(5$&7 LQLWLDWLYHFRXOGVHUYHDVDQH[DPSOH 2XWFRPHPHDVXUHV
VKRXOGEHVHOHFWHGIRUHDFKFRUHDUHDRI SK\VLRWKHUDS\LQ3' JDLWSRVWXUHDQGEDODQFH
WUDQVIHUVGH[WHULW\DQGSK\VLFDOFDSDFLW\7KHRXWFRPHPHDVXUHWREHFKRVHQLQDVWXG\
WKHQGHSHQGVRQWKHVSHFLÀFDLPRIWKHLQWHUYHQWLRQEHLQJVWXGLHG
6HHLQJWKHQDWXUHRISK\VLRWKHUDS\ZKLFKPDLQO\DLPVWRLPSURYHDFWLYLW\OLPLWDWLRQV
SULRULW\QHHGVWREHJLYHQWRRXWFRPHPHDVXUHVDWWKHOHYHORIDFWLYLWLHV+RZHYHULP
SURYHPHQWVLQFOLQLFDOPHDVXUHVPD\QRWQHFHVVDULO\FRUUHVSRQGWRLPSURYHPHQWVLQKRZ
WKHSDWLHQWIXQFWLRQVRUIHHOV7KHUHIRUHDSDWLHQWUHSRUWHGPHDVXUHVKRXOGEHXVHGLQ
DGGLWLRQWRDSK\VLRORJLFRXWFRPH HJHYDOXDWLQJJDLWYHORFLW\
&RQVLGHULQJWKHGLYHUVHQDWXUHRIDFWLYLW\OLPLWDWLRQVVHHQDFURVVGLIIHUHQWLQGLYLGXDOV
ZLWK3'HYHQZLWKLQRQHSK\VLRWKHUDS\FRUHDUHDLWZLOOEHGLIÀFXOWLIQRWLPSRVVLEOH
WRFKRRVHD¶RQHVL]HÀWVDOO·RXWFRPHPHDVXUH$SDWLHQWUHSRUWHGSDWLHQWVSHFLÀF
RXWFRPHPHDVXUHFDQE\SDVVWKLVSUREOHPE\HYDOXDWLQJWKHVSHFLÀFDFWLYLW\OLPLWDWLRQV
WKDWDUHPRVWERWKHUVRPHWRHDFKLQGLYLGXDOSDWLHQW([DPSOHVRISDWLHQWVSHFLÀFLQVWUX
PHQWVDUHWKH0$&7$5WKH3DWLHQW6SHFLÀF)XQFWLRQDO6FDOHWKH3DWLHQW6SHFLÀF
,QGH[ WKH&230DQGWKH36,3' &KDSWHU
)LQDOO\ZHZLOOEULHÁ\GLVFXVVWKHZLGHO\KHDUGFRQFHUQWKDWFRQFXUUHQWFKDQJHVLQDQWL
3DUNLQVRQPHGLFDWLRQGXULQJDWULDOPD\REVFXUHWKH¶SXUH·HIIHFWVRISK\VLRWKHUDS\,W
LVREYLRXVO\WUXHWKDWPHGLFDWLRQUHJLPHVVKRXOGLGHDOO\EHNHSWFRQVWDQWLIRQHDLPV
WRGHWHUPLQHWKHLQWULQVLFHIÀFDF\RISK\VLRWKHUDS\,QHYHU\GD\FOLQLFDOSUDFWLFHWKLVLV
RIWHQQRWIHDVLEOHFHUWDLQO\ZKHQSDWLHQWVKDYHWREHIROORZHGIRUWKHUHFRPPHQGHGSUR
ORQJHGSHULRGVRI WLPHDVLVUHFRPPHQGHG,QWKLVFDVHDJRRGDOWHUQDWLYHLVWRFDUHIXOO\
GRFXPHQWDQ\FKDQJHVLQGUXJWKHUDS\WKURXJKRXWWKHVWXG\SHULRGDQGWRWUHDWWKHVH
PHGLFDWLRQDGMXVWPHQWVHLWKHUDVDFRQIRXQGHURUEHWWHUHYHQDVDVHFRQGDU\RXWFRPH
PHDVXUH$FRQFHLYDEOHRXWFRPHLVWKDWSK\VLRWKHUDS\PD\REYLDWHWKHQHHGWRGUDVWLFDOO\
LQFUHDVHWKHGRVHRIDQWLSDUNLQVRQPHGLFDWLRQ
3XEOLFDWLRQ
1HZWULDOVVKRXOGEHUHJLVWHUHGLQDGDWDEDVHIRUFOLQLFDOWULDOVEHIRUHWKHVWDUWRI SDWLHQW
UHFUXLWPHQW7KHUHVXOWVRIWKHVHWULDOVVKRXOGEHSXEOLVKHGDFFRUGLQJWRWKH&216257
VWDWHPHQW
,PSOHPHQWDWLRQRI HYLGHQFHLQWRFDUH
7KHUHDUHWKUHHLPSRUWDQWSUREOHPVLQHYHU\GD\FOLQLFDOSUDFWLYHWKDWWKUHDWHQWKHTXD
OLW\RI SK\VLRWKHUDS\LQ3' D ODFN3'VSHFLÀFH[SHUWLVHLQSK\VLRWKHUDSLVWV E WKH
VPDOOYROXPHRI 3'SDWLHQWVWUHDWHGDQQXDOO\E\HDFKLQGLYLGXDOSK\VLRWKHUDSLVW F WKH
LQDFFXUDF\RI UHIHUUDOV DQG G WKHJHQHUDOO\SRRUFRPPXQLFDWLRQEHWZHHQKHDOWKFDUH
SURYLGHUVLQYROYHGLQ3'FDUH HJEHWZHHQSK\VLRWKHUDSLVWVDQGUHIHUULQJQHXURORJLVWV DQGZLWKSDWLHQWV
7KHODFNRI 3'VSHFLÀFH[SHUWLVHLVSDUWO\LQKHUHQWWRWKHORZYROXPHRI 3'SDWLHQWV
WUHDWHGE\HDFKWKHUDSLVW(YHQLQWKH1HWKHUODQGVZKHUHSK\VLRWKHUDS\LVFRPPRQO\
SUHVFULEHGHDFKWKHUDSLVWW\SLFDOO\WUHDWVDWPRVWWKUHHSDWLHQWVHDFK\HDU &KDSWHU
$GGLWLRQDOUHDVRQVIRUWKHODFNRI H[SHUWLVHLQFOXGHWKHDEVHQFHRISUDFWLFDOJXLGHOLQHV
DQGWKHDYDLODELOLW\RI KLJKTXDOLW\FRPSHWHQFHRULHQWHGHGXFDWLRQ2QHJXLGHOLQHKDV
EHFRPHDYDLODEOHLQ &KDSWHU +RZHYHUVLPSO\SXEOLFDWLRQDQGGLVVHPLQDWLRQRI
DJXLGHOLQHGRHVQRWQHFHVVDULO\JXDUDQWHHZLGHVSUHDGXVHLQFOLQLFDOSUDFWLFH&RQVLGH
UDEOHDWWHQWLRQVKRXOGWKHUHIRUHEHIRFXVHGRQJXLGHOLQHLPSOHPHQWDWLRQ+RZHYHULWLV
XQFOHDUZKLFKJXLGHOLQHLPSOHPHQWDWLRQVWUDWHJLHVDUHOLNHO\WREHPRVWHIÀFLHQW
3DUNLQVRQ1HW
2QHRSWLRQWRWDFNOHDOOWKUHHRIWKHDIRUHPHQWLRQHGSUREOHPVLVWKHGHYHORSPHQWRI FRPPXQLW\EDVHGQHWZRUNVRI GHGLFDWHGKHDOWKSURIHVVLRQDOVVSHFLDOLVHGLQ3'6XFK
*HQHUDOGLVFXVVLRQDQGIXWXUHFKDOOHQJHV UHJLRQDOQHWZRUNVKDYHUHFHQWO\EHHQLQWURGXFHGLQWKH1HWKHUODQGVXQGHUWKHQDPH
3DUNLQVRQ1HW
7KHFHQWUDOLGHDRI 3DUNLQVRQ1HWLVWKDWZLWKLQDJLYHQUHJLRQ3'SDWLHQWVVKRXOG
SUHIHUHQWLDOO\EHWUHDWHGE\DVPDOOJURXSRI VHOHFWHGSURIHVVLRQDOVZLWKDKLJKGHJUHH
RI H[SHUWLVHLQ3' WKLVLQFOXGHVERWKDOOLHGKHDOWKSURIHVVLRQDOVDQGSK\VLFLDQV 7KLV
H[SHUWLVHLVJDLQHGLQLWLDOO\GXULQJDQLQWHQVLYHWUDLQLQJFRXUVHDQGLVPDLQWDLQHGDWDKLJK
OHYHOEHFDXVHSDWLHQWVDUHEHLQJUHIHUUHGVSHFLÀFDOO\WRWKHVH3DUNLQVRQ1HWWKHUDSLVWV
&RQVHTXHQWO\WKHLUWUHDWPHQWYROXPHLQFUHDVHVFRQVLGHUDEO\DOORZLQJWKHUDSLVWVWRFRQ
WLQXRXVO\DSSO\DQGH[WHQGWKHLUH[SHUWLVHLQFOLQLFDOSUDFWLFH)XUWKHUPRUHWKHSDUWLFL
SDWLQJDOOLHGKHDOWKSURIHVVLRQDOVUHFHLYHFRQWLQXRXVHGXFDWLRQVXSSRUWHGE\DZHE
EDVHGWUDLQLQJDQGFRPPXQLFDWLRQIDFLOLW\)LQDOO\D3'VSHFLÀFHOHFWURQLFSDWLHQWUHFRUG
(35 LVXVHGZKLFKVXSSRUWVFOLQLFDOGHFLVLRQPDNLQJEDVHGRQSXEOLVKHGHYLGHQFH
RIIHUVVXSSRUWIRUFRPPXQLFDWLRQDQGSURYLGHVURXWLQHIHHGEDFNIURPSDWLHQWVWRWKH
KHDOWKFDUHSURYLGHUWKURXJKLQWHUQHWEDVHGVXUYH\V7UHDWPHQWGXUDWLRQFDQEHUHGXFHG
E\SURYLGLQJWKHUDSLVWVZLWKFOHDUFULWHULDWRVWRSWUHDWPHQWZKHQWKHJRDOVKDYHEHHQ
UHDFKHG7KH3DUNLQVRQ1HWFRQFHSWDVVXPHVDQDFWLYHUROHIRUSDWLHQWVDQGWKHLUIDPLOLHV
SDWLHQWHPSRZHUPHQW IRUH[DPSOHE\XVLQJDVLPSOHVFUHHQLQJWRROIRUVHOIDVVHVVPHQW
DQGVHOIUHIHUUDODQGE\FODULI\LQJWRSDWLHQWVZKHUHWKH3DUNLQVRQ1HWWKHUDSLVWVFDQEH
IRXQGLQWKHLUUHJLRQ3DWLHQWVDOVRKDYHDFFHVVWRWKHLURZQ(35)XUWKHULPSRUWDQW
HOHPHQWVRI3DUNLQVRQ1HWLQFOXGHLPSURYHGFRPPXQLFDWLRQDPRQJDOOKHDOWKSURIHVVLR
QDOVLQYROYHGLQ3'FDUHDQGVWUXFWXULQJRIWKHUHIHUUDOSURFHVV E\SURPRWLQJGHGLFDWHG
UHIHUUDOVWR3DUNLQVRQ1HWWKHUDSLVWV
:RUOGZLGH
7KHTXHVWLRQDULVHVZKHWKHUWKLV3DUNLQVRQ1HWFRQFHSWFDQDOVREHH[WUDSRODWHGWRRWKHU
FRXQWULHVZKHUHWKHRUJDQLVDWLRQRI KHDOWKFDUHLVGLIIHUHQWDQGZKHUHRWKHUKHDOWKFDUH
LQVXUDQFHPRGHOVDUHLQSODFH*HQHUDOO\VSHDNLQJLPSOHPHQWDWLRQRIQHWZRUNFDUH
ZLOOEHKDPSHUHGE\DKHDOWKFDUHV\VWHPWKDWRIIHUVVHSDUDWHIXQGLQJIRUWKHGLIIHUHQW
FRPSRQHQWVRIWKHQHWZRUN:HVXVSHFWWKDWVLQJOHSD\HUV\VWHPVZKHUHWKHJRYHUQ
PHQWJXDUDQWHHVWKDWHYHU\FLWL]HQZLOOKDYHDKHDOWKLQVXUDQFH ZLWKDQRSWLRQIRUSULYDWH
LQVXUDQFH DVLVSUHVHQWLQFRXQWULHVVXFKDVWKH8QLWHG.LQJGRP*HUPDQ\RU&DQDGD
ZLOOIDFLOLWDWHLPSOHPHQWDWLRQ,QFRQWUDVWDSOXUDOLVWLFKHDOWKFDUHV\VWHPVXFKDVIRXQG
LQWKH86$PLJKWSURYLGHEDUULHUVIRULPSOHPHQWDWLRQ7KHOHYHOVRI IXQGLQJRI DO
OLHGKHDOWKFDUH ZKLFKFDQGLIIHUPDUNHGO\DFURVVGLIIHUHQWFRXQWULHV PD\DOVRKDPSHU
LPSOHPHQWDWLRQIRUH[DPSOHZKHQSDWLHQWVKDYHWRSD\IRUDWOHDVWSDUWRIWKHFRVWV
WKHPVHOYHV1HYHUWKHOHVVZHH[SHFWWKDWEDUULHUVSURYLGHGE\WKHRUJDQLVDWLRQRI KHDOWK
FDUHV\VWHPVPD\EHRYHUFRPHE\WKHLQFHQWLYHVDVLQGLFDWHGDERYHWKDWDUHRIIHUHG
WRHJJRYHUQPHQWVKHDOWKLQVXUDQFHFRPSDQLHVRURWKHUIXQGLQJERGLHVIRUH[DPSOH
E\LPSURYLQJWKHHIÀFLHQF\RIFDUHE\DFWLYHO\HQJDJLQJSDWLHQWVLQWKHLURZQKHDOWK
SURJUDPE\DYRLGLQJXQQHFHVVDULO\SURORQJHGWUHDWPHQWVDQGE\GHFUHDVLQJRYHUXVHRU
LQDSSURSULDWHXVHRI FDUH1RWHWKDWWKH3DUNLQVRQ1HWFRQFHSWLVSUREDEO\PRVWYLDEOH
ZLWKLQGHQVHO\SRSXODWHGDUHDV2WKHULQLWLDWLYHVWDUJHWHGWROHVVGHQVHO\SRSXODWHGDUHDV
XVHHJFRPSHWHQFHEDVHGHGXFDWLRQ ¶WUDLQWKHWUDLQHU· $FFRUGLQJWRWKLVFRQFHSW
H[LVWLQJKHDOWKFDUHUHVRXUFHVZLWKLQFRPPXQLWLHV HJVSRUWVLQVWUXFWRUV RUFDUHJLYHUV
DUHWUDLQHGWRFDUU\RXWSDUWVRIWKHHYLGHQFHEDVHGSUDFWLFHVXFKDVWKHSURPRWLRQRI DQRQJRLQJSK\VLFDODFWLYLW\SURJUDP7KLVFDQEHVXSSRUWHGE\FRPSXWHUEDVHGOHDUQLQJ
HQYLURQPHQWVLQFOXGLQJWKHDSSOLFDWLRQRIDQ LQWHUDFWLYH &'520$OVRZHEEDVHG
LQWHUYHQWLRQVPLJKWSDUWRIWKHVROXWLRQLQWKHVHOHVVGHQVHSRSXODWHGDUHDV
7KHÀUVWUHVXOWVRIWKH3DUNLQVRQ1HW7ULDOVXJJHVWWKDWWKHLPSOHPHQWDWLRQRI3DUNLQ
VRQ1HWLQFUHDVHVWKHWUHDWPHQWYROXPHSHUWKHUDSLVWIURPDURXQGIRXUSDWLHQWVSHU\HDU
WRLQFUHDVHVWKHTXDOLW\RIFDUHZKLOHLWGHFUHDVHVWKHWUHDWPHQWGXUDWLRQDQGWKH
FRVWVIRUVRFLHW\
0XOWLGLVFLSOLQDU\QHWZRUNFDUH
:KHQGRHVHYLGHQFHEDVHGFDUHWXUQLQWRRSWLPDOFDUH",WLVXQOLNHO\WKDWSK\VLRWKHUDSLVW
FDQGHOLYHURSWLPDODQGFRPSUHKHQVLYHFDUHWR3'SDWLHQWVMXVWE\WKHPVHOYHV,QGHHG
GXHWRWKHFRPSOH[DQGSURJUHVVLYHQDWXUHRI3'DZLGHDUUD\RIGLIÀFXOWLHVPD\EH
H[SHULHQFHG &KDSWHU ,QRUGHUWRDGGUHVVWKHVHGLIÀFXOWLHVPDQ\SDWLHQWVUHTXLUH
PXOWLGLVFLSOLQDU\FDUH )LJXUH ,QWKH1HWKHUODQGVJXLGHOLQHVIRUPXOWLGLVFLSOLQDU\
1HXUR SV\FKRORJLVW
6H[RORJLVW +RPHFDUH
3$7,(17 VLJQLILFDQW
RWKHU
1HXURORJLVW 3'QXUVHVSHFLDOLVW 1HXURVXUJHRQ
3K\VLRWKHUDSLVW 2FFXSDWLRQDO
WKHUDSLVW 6SHHFKWKHUDSLVW 'LHWLFLDQ
&OLQLFDO
JHULDWULFLDQ
3V\FKLDWULVW
3KDUPDFLVW
1XUVLQJKRPHRU
UHKDELOLWDWLRQVSHFLDOLVW
*HQHUDO
3UDFWLWLRQHU
3DUNLQVRQ¶V
'LVHDVH
6RFLHW\ 3'([SHUWLVH&HQWUH
6RFLDOZRUNHU
5HJLRQDODOZD\ VLQYROYHG
5HJLRQDOLQY ROYHGZKHQLQGLFDWHG KRVSLWDORUFRPPXQLW\EDVHG 6XSUDUHJLRQDOLQYROYHGZ KHQLQGLFDWHG
)LJXUH2UJDQLVDWLRQRI FDUHLQ3DUNLQVRQGLVHDVH
*HQHUDOGLVFXVVLRQDQGIXWXUHFKDOOHQJHV FDUHKDYHUHFHQWO\EHHQGHYHORSHG ,QDGGLWLRQWRUHFRPPHQGDWLRQVIRUHYL
GHQFHGEDVHGFDUHWKHVHJXLGHOLQHVFRQWDLQUHFRPPHQGDWLRQVWRRSWLPDOLVHWKHRUJDQLVD
WLRQRI PXOWLGLVFLSOLQDU\FDUH7KHUHTXLUHPHQWVIRURSWLPDOFDUHLQ3'ZHUHLGHQWLÀHG
WKURXJKIRFXVJURXSLQWHUYLHZVDQGFRQVHQVXVPHHWLQJV3'SDWLHQWVDQGKHDOWKFDUH
SURIHVVLRQDOVUHSUHVHQWLQJDOOGLVFLSOLQHVLQYROYHGLQWKHFDUHRISDWLHQWVZLWK3'ZHUH
LQYROYHGLQWKLVSURFHVV7KHVHUHTXLUHPHQWVLQFOXGHDQDGHTXDWHOHYHORI H[SHUWLVHJRRG
FRPPXQLFDWLRQDQGLQWHUGLVFLSOLQDU\FROODERUDWLRQFOHDUFRRUGLQDWLRQRI FDUHDQGVROLG
ÀQDQFLDOXQGHUSLQQLQJ$OWKRXJKVSHFLÀFUHFRPPHQGDWLRQVWRPHHWWKHVHFRQGLWLRQV
PD\YDU\EHWZHHQFRXQWULHVWKHFRQGLWLRQVWKHPVHOYHVDUHOLNHO\WREHDSSOLFDEOHWR3'
FDUHLQPDQ\FRXQWULHV
0RUHRYHULILPSOHPHQWDWLRQRI3DUNLQVRQ1HWSURYHVVXFFHVVIXODYDOXDEOHHQYLURQPHQW
LVFUHDWHGIRUWKHLPSOHPHQWDWLRQRIRSWLPDOO\RUJDQLVHGPXOWLGLVFLSOLQDU\JXLGHOLQH
EDVHGFDUH/LNHSK\VLRWKHUDS\DOVRRWKHUDOOLHGKHDOWKFDUHLQ3'LVKDPSHUHGE\LQ
DGHTXDWHRUJDQLVDWLRQDQGH[SHUWLVH:KHQWKHVL]HRI WKHUHJLRQDOQHWZRUNVLVZHOO
WXQHGWRWKHQXPEHURI SDWLHQWVOLYLQJLQWKHUHJLRQWUHDWPHQWYROXPHVRI KHDOWK
SURIHVVLRQDOVZLOOLQFUHDVHLQFUHDVLQJSDWLHQWDQGSURFHVVRXWFRPH ,QDGGLWLRQWKH
GHVLJQRI WKH3DUNLQVRQ1HWWULDOPLJKWSURYLGHDJRRGWHPSODWHIRUIXWXUHHYDOXDWLRQ
VWXGLHVRIRWKHUFRPSOH[LQWHUYHQWLRQVLQDOOLHGKHDOWKFDUH
