Treadmill gait training improves baroreflex sensitivity in Parkinson's disease

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements. We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 154 RCTs with a total of 7837 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 60 (2721 participants), and 48 (3029 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson's Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (60 studies; 2721 participants) suggests that dance and gait/balance/functional training probably have a moderate beneficial effect on the severity of motor signs (dance: mean difference (MD) -10.18, 95% confidence interval (CI) -14.87 to -5.36; gait/balance/functional training: MD -7.50, 95% CI -11.39 to -3.48; moderate confidence), and multi-domain training probably has a small beneficial effect on the severity of motor signs (MD -5.90, 95% CI -9.11 to -2.68; moderate confidence). The evidence also suggests that endurance, aqua-based, strength/resistance, and mind-body training might have a small beneficial effect on the severity of motor signs (endurance training: MD -5.76, 95% CI -9.78 to -1.74; aqua-based training: MD -5.09, 95% CI -10.45 to 0.40; strength/resistance training: MD -4.96, 95% CI -9.51 to -0.40; mind-body training: MD -3.62, 95% CI -7.24 to 0.00; low confidence). The evidence is very uncertain about the effects of "Lee Silverman Voice training BIG" (LSVT BIG) and flexibility training on the severity of motor signs (LSVT BIG: MD -6.70, 95% CI -16.48 to 3.08; flexibility training: MD 4.20, 95% CI -1.61 to 9.92; very low confidence). Quality of life The evidence from the NMA (48 studies; 3029 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -15.15, 95% CI -23.43 to -6.87; moderate confidence). The evidence also suggests that mind-body, gait/balance/functional, and multi-domain training and dance might have a small beneficial effect on QoL (mind-body training: MD -7.22, 95% CI -13.57 to -0.70; gait/balance/functional training: MD -6.17, 95% CI -10.75 to -1.59; multi-domain training: MD -5.29, 95% CI -9.51 to -1.06; dance: MD -3.88, 95% CI -10.92 to 3.00; low confidence). The evidence is very uncertain about the effects of gaming, strength/resistance, endurance, and flexibility training on QoL (gaming: MD -8.99, 95% CI -23.43 to 5.46; strength/resistance training: MD -6.70, 95% CI -12.86 to -0.35; endurance training: MD -6.52, 95% CI -13.74 to 0.88; flexibility training: MD 1.94, 95% CI -10.40 to 14.27; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Physical exercise for people with Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Physical exercise is effective in managing Parkinson's disease (PD), but the relative benefit of different exercise types remains unclear.

OBJECTIVES

To compare the effects of different types of physical exercise in adults with PD on the severity of motor signs, quality of life (QoL), and the occurrence of adverse events, and to generate a clinically meaningful treatment ranking using network meta-analyses (NMAs).

SEARCH METHODS

An experienced information specialist performed a systematic search for relevant articles in CENTRAL, MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial registries, conference proceedings, and reference lists of identified studies up to this date.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing one type of physical exercise for adults with PD to another type of exercise, a control group, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. A third author was involved in case of disagreements.  We categorized the interventions and analyzed their effects on the severity of motor signs, QoL, freezing of gait, and functional mobility and balance up to six weeks after the intervention using NMAs. Two review authors independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and rated the confidence in the evidence using the CINeMA approach for results on the severity of motor signs and QoL. We consulted a third review author to resolve any disagreements. Due to heterogeneous reporting of adverse events, we summarized safety data narratively and rated our confidence in the evidence using the GRADE approach.

MAIN RESULTS

We included 156 RCTs with a total of 7939 participants with mostly mild to moderate disease and no major cognitive impairment. The number of participants per study was small (mean 51, range from 10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five studies (5192 participants) provided safety data. Here, we present the main results. We observed evidence of beneficial effects for most types of physical exercise included in our review compared to a passive control group. The effects on the severity of motor signs and QoL are expressed as scores on the motor scale of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores denote higher symptom burden. Therefore, negative estimates reflect improvement (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) suggests that dance has a moderate beneficial effect on the severity of motor signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; high confidence), and aqua-based, gait/balance/functional, and multi-domain training might have a moderate beneficial effect on the severity of motor signs (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low confidence). The evidence also suggests that mind-body training and endurance training might have a small beneficial effect on the severity of motor signs (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 to -2.28; low confidence). Flexibility training might have a trivial or no effect on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). The evidence is very uncertain about the effects of strength/resistance training and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the NMA (55 studies; 3283 participants) suggests that aqua-based training probably has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate confidence). The evidence also suggests that endurance training might have a moderate beneficial effect, and that gait/balance/functional and multi-domain training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is very uncertain about the effects of mind-body training, gaming, strength/resistance training, dance, LSVT BIG, and flexibility training on QoL (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 studies (5192 participants) provided some kind of safety data, mostly only for the intervention groups. No adverse events (AEs) occurred in 40 studies and no serious AEs occurred in four studies. AEs occurred in 28 studies. The most frequently reported events were falls (18 studies) and pain (10 studies). The evidence is very uncertain about the effect of physical exercise on the risk of adverse events (very low confidence). Across outcomes, we observed little evidence of differences between exercise types.

AUTHORS' CONCLUSIONS

We found evidence of beneficial effects on the severity of motor signs and QoL for most types of physical exercise for people with PD included in this review, but little evidence of differences between these interventions. Thus, our review highlights the importance of physical exercise regarding our primary outcomes severity of motor signs and QoL, while the exact exercise type might be secondary. Notably, this conclusion is consistent with the possibility that specific motor symptoms may be treated most effectively by PD-specific programs. Although the evidence is very uncertain about the effect of exercise on the risk of adverse events, the interventions included in our review were described as relatively safe. Larger, well-conducted studies are needed to increase confidence in the evidence. Additional studies recruiting people with advanced disease severity and cognitive impairment might help extend the generalizability of our findings to a broader range of people with PD.

Systematic review for the prevention and management of falls and fear of falling in patients with Parkinson's disease

OBJECTIVE

To synthesize recent empirical evidence for the prevention and management of falls and fear of falling in patients with Parkinson's disease (PD).

DATA SOURCE

Database from PubMed, Cochrane Library, and EMBASE.

STUDY DESIGN

Systematic review.

DATA COLLECTION

We searched the PubMed, Cochrane Library, and EMBASE databases for studies published from inception to February 27, 2021. Inclusion criteria were nonreview articles on prevention and management measures related to falls and fall prevention in Parkinson's disease patients.

PRINCIPAL FINDINGS

We selected 45 articles and conducted in-depth research and discussion. According to the causes of falls in PD patients, they were divided into five directions, namely physical status, pre-existing conditions, environment, medical care, and cognition. In the cognitive domain, we focused on the fear of falling. On the above basis, we constructed a fall prevention model, which is a tertiary prevention health care network, based on The Johns Hopkins Fall Risk Assessment Tool to provide ideas for the prevention and management of falling and fear of falling in PD patients in clinical practice CONCLUSIONS: Falls and fear of falls in patients with Parkinson's disease can be reduced by effective clinical prevention and management. Future studies are needed to explore the efficacy of treatment and prevention of falls and fear of falls.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Autonomic Function in Patients With Parkinson's Disease: From Rest to Exercise

Parkinson’s disease (PD) is a common neurodegenerative disorder classically characterized by symptoms of motor impairment (e.g., tremor and rigidity), but also presenting with important non-motor impairments. There is evidence for the reduced activity of both the parasympathetic and sympathetic limbs of the autonomic nervous system at rest in PD. Moreover, inappropriate autonomic adjustments accompany exercise, which can lead to inadequate hemodynamic responses, the failure to match the metabolic demands of working skeletal muscle and exercise intolerance. The underlying mechanisms remain unclear, but relevant alterations in several discrete central regions (e.g., dorsal motor nucleus of the vagus nerve, intermediolateral cell column) have been identified. Herein, we critically evaluate the clinically significant and complex associations between the autonomic dysfunction, fatigue and exercise capacity in PD.

Baroreflex dysfunction in Parkinson's disease: integration of central and peripheral mechanisms

The incidence of Parkinson's disease (PD) is increasing worldwide. Although the PD hallmark is the motor impairments, nonmotor dysfunctions are now becoming more recognized. Recently, studies have suggested that baroreflex dysfunction is one of the underlying mechanisms of cardiovascular dysregulation observed in patients with PD. However, the large body of literature on baroreflex function in PD is unclear. The baroreflex system plays a major role in the autonomic, and ultimately blood pressure and heart rate, adjustments that accompany acute cardiovascular stressors on a daily basis. Therefore, impaired baroreflex function (i.e., decreased sensitivity or gain) can lead to altered neural cardiovascular responses. Since PD affects parasympathetic and sympathetic branches of the autonomic nervous system and both are orchestrated by the baroreflex system, understanding of this crucial mechanism in PD is necessary. In the present review, we summarize the potential altered central and peripheral mechanisms affecting the feedback-controlled loops that comprise the reflex arc in patients with PD. Major factors including arterial stiffness, reduced number of C1 and activation of non-C1 neurons, presence of central α-synuclein aggregation, cardiac sympathetic denervation, attenuated muscle sympathetic nerve activity, and lower norepinephrine release could compromise baroreflex function in PD. Results from patients with PD and from animal models of PD provide the reader with a clearer picture of baroreflex function in this clinical condition. By doing so, our intent is to stimulate future studies to evaluate several unanswered questions in this research area.

Baroreflex function in Parkinson's disease: insights from the modified-Oxford technique

Nonmotor symptoms are common in Parkinson's disease (PD) and they include dysregulation of cardiovascular system, which adversely affects quality of life. Recent studies provide indirect evidence that baroreflex dysfunction may be one of the mechanisms of cardiovascular dysregulation in PD. Herein, we tested the hypothesis that the baroreflex gain, assessed across an extensive range of the reflex arc by eliciting rapid changes in blood pressure (BP) induced by sequential boluses of vasoactive drugs (modified-Oxford technique) would be attenuated in middle-aged patients with PD. Beat-to-beat heart rate (electrocardiography) and BP (finger photoplethysmography) were obtained during 10 min of supine rest preceding the modified-Oxford (bolus of nitroprusside followed by phenylephrine 1 min afterward) in 11 patients with PD (51 ± 6 yr) and 7 age-matched controls (47 ± 6 yr). The resulting systolic BP and R-R interval responses were plotted and fitted with segmental linear regression and symmetric sigmoid model. Spontaneous indices obtained via sequence technique were also used to estimate baroreflex gain. Compared with controls, the estimated gains measured by segmental linear regression (patients: 3.83 ± 2.6 ms/mmHg versus controls: 7.78 ± 1.7 ms/mmHg; P = 0.003) and symmetric sigmoid model (patients: 12.36 ± 6.9 ms/mmHg versus controls: 32.02 ± 19.0 ms/mmHg; P = 0.009) were lower in patients with PD. The operating range of BP was larger in patients with PD compared with controls (13 ± 7 mmHg versus controls: 7 ± 3 mmHg; P = 0.032). Of note, the gain obtained from spontaneous indices was similar between groups. These data indicate that baroreflex gain was reduced by >50% in PD, thereby providing clear and direct evidence that cardiovagal baroreflex dysfunction occurs in PD.NEW & NOTEWORTHY Attenuated baroreflex gain may contribute to adverse cardiovascular outcomes, including orthostatic intolerance symptoms typically observed in patients with Parkinson's disease. We found that the baroreflex gain (assessed by the modified-Oxford technique) is attenuated and accompanied by an increased operating range in patients with Parkinson's disease. These findings highlight that cardiovascular perturbations are required to detect baroreflex impairments and that spontaneous indices do not reveal cardiovagal-baroreflex dysfunction in a middle-aged group of patients with Parkinson's disease.

Altered cardiorespiratory regulation during exercise in patients with Parkinson's disease: A challenging non-motor feature

The incidence of Parkinson’s disease is increasing worldwide. The motor dysfunctions are the hallmark of the disease, but patients also experience non-motor impairments, and over 40% of the patients experience coexistent abnormalities, such as orthostatic hypotension. Exercise training has been suggested as a coping resource to alleviate Parkinson’s disease symptoms and delay disease progression. However, the body of knowledge is showing that the cardiovascular response to exercise in patients with Parkinson’s disease is altered. Adequate cardiovascular and hemodynamic adjustments to exercise are necessary to meet the metabolic demands of working skeletal muscle properly. Therefore, since Parkinson’s disease affects parasympathetic and sympathetic branches of the autonomic nervous system and the latter are crucial in ensuring these adjustments are adequately made, the understanding of these responses during exercise in this population is necessary. Several neural control mechanisms are responsible for the autonomic changes in the cardiovascular and hemodynamic systems seen during exercise. In this sense, the purpose of the present work is to review the current knowledge regarding the cardiovascular responses to dynamic and isometric/resistance exercise as well as the mechanisms by which the body maintains appropriate perfusion pressure to all organs during exercise in patients with Parkinson’s disease. Results from patients with Parkinson’s disease and animal models of Parkinson’s disease provide the reader with a well-rounded knowledge base. Through this, we will highlight what is known and not known about how the neural control of circulation is responding during exercise and the adaptations that occur when individuals exercise regularly.

Body Weight Support Combined With Treadmill in the Rehabilitation of Parkinsonian Gait: A Review of Literature and New Data From a Controlled Study

Background: Gait disorders represent disabling symptoms in Parkinson's Disease (PD). The effectiveness of rehabilitation treatment with Body Weight Support Treadmill Training (BWSTT) has been demonstrated in patients with stroke and spinal cord injuries, but limited data is available in PD. Aims: The aim of the study is to investigate the efficacy of BWSTT in the rehabilitation of gait in PD patients. Methods: Thirty-six PD inpatients were enrolled and performed rehabilitation treatment for 4-weeks, with daily sessions. Subjects were randomly divided into two groups: both groups underwent daily 40-min sessions of traditional physiokinesitherapy followed by 20-min sessions of overground gait training (Control group) or BWSTT (BWSTT group). The efficacy of BWSTT was evaluated with clinical scales and Computerized Gait Analysis (CGA). Patients were tested at baseline (T0) and at the end of the 4-weeks rehabilitation period (T1). Results: Both BWSTT and Control groups experienced a significant improvement in clinical scales as FIM and UPDRS and in gait parameters for both interventions. Even if we failed to detect any statistically significant differences between groups in the different clinical and gait parameters, the intragroup analysis captured a specific pattern of qualitative improvement associated to cadence and stride duration for the BWSTT group and to the swing/stance ratio for the Control group. Four patients with chronic pain or anxious symptoms did not tolerate BWSTT. Conclusions: BWSTT and traditional rehabilitation treatment are both effective in improving clinical motor functions and kinematic gait parameters. BWSTT may represent an option in PD patients with specific symptoms that limit traditional overground gait training, e.g., severe postural instability, balance disorder, orthostatic hypotension. BWSTT is generally well-tolerated, though caution is needed in subjects with chronic pain or with anxious symptoms. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03815409.

Influence of age and gender on blood pressure variability and baroreflex sensitivity in a healthy population in the Indian sub-continent

Background The current exploratory study was aimed at estimating measures of blood pressure variability (BPV) and baroreflex sensitivity (BRS) in a healthy population in the Indian sub-continent. Methods One hundred and forty-two healthy subjects were recruited for the study. Blood pressure (BP) was recorded continuously for 15 min using the Finometer (Finapres Medical Systems, The Netherlands). For offline analysis, Nevrokard cardiovascular parameter analysis (CVPA) software (version 2.1.0) was used for BPV analysis. BRS was determined by spectral and sequence methods. One-way ANOVA and Bonferroni's test were used to compare parameters. Pearson's correlation coefficient was employed to look for possible associations between age and other continuous variables. Results Out of 196 screened volunteers, 54 were excluded and 142 subjects were grouped based on ages as 10-19 years (group 1), 20-29 years (group 2), 30-39 years (group 3), 40-49 years (group 4), and 50-59 years (group 5). Within groups, body mass index (BMI, p=0.000) and BP (systolic and diastolic) were significantly different. Post hoc analysis showed mean blood pressure (MBP) and diastolic blood pressure (DBP) differing significantly between groups 1 and 4 (p<0.05 for both) along with other cardiovascular parameters. Age correlated positively with BMI and all parameters of BP. Significant gender differences were observed for stroke volume, cardiac output, up BRS, total BRS, peripheral resistance (PR), and aortic impedance. Conclusions Our study has provided reference values for BPV and BRS in an Indian population. It also indicates age-related neurocardiac imbalance and possible utility of these tests for screening at the start of neurocardiac damage in a healthy population.

Research in Parkinson's disease in India: A review

Parkinson's disease (PD) is a common neurodegenerative disorder affecting patients in large numbers throughout the world. In this article, we review all the published data on PD based on studies in Indian population. We have tried to consolidate the contribution of Indian studies in PD research. We found 95 articles, of which 92 were original research papers. This is a relatively less number, but in the last decade, there has been an increase in research on PD from this country. But most of them seem to be restricted to only a few research institutes. The nonmotor symptoms and genetics are the most commonly studied aspects. The systematic review of the articles reveals that the epidemiology in India may be different with relatively lesser incidence here. Most of the genetic mutations found to cause PD in other population are not found in India, revealing that other genetic factors may be involved. Further research needs to be encouraged to understand the disease in Indian patients better, as all the results cannot be extrapolated from the Western literature to this heterogeneous Indian population. There need to be more studies on therapeutic aspects of the disease.

Treadmill training for patients with Parkinson's disease

BACKGROUND

Treadmill training is used in rehabilitation and is described as improving gait parameters of patients with Parkinson's disease.

OBJECTIVES

To assess the effectiveness of treadmill training in improving the gait of patients with Parkinson's disease and the acceptability and safety of this type of therapy.

SEARCH METHODS

We searched the Cochrane Movement Disorders Group Specialised Register (see Review Group details for more information) (last searched September 2014), Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 10), MEDLINE (1950 to September 2014), and EMBASE (1980 to September 2014). We also handsearched relevant conference proceedings, searched trials and research registers, and checked reference lists (last searched September 2014). We contacted trialists, experts and researchers in the field and manufacturers of commercial devices.

SELECTION CRITERIA

We included randomised controlled trials comparing treadmill training with no treadmill training in patients with Parkinson's disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted data. We contacted the trialists for additional information. We analysed the results as mean differences (MDs) for continuous variables and relative risk differences (RD) for dichotomous variables.

MAIN RESULTS

We included 18 trials (633 participants) in this update of this review. Treadmill training improved gait speed (MD = 0.09 m/s; 95% confidence interval (CI) 0.03 to 0.14; P = 0.001; I(2) = 24%; moderate quality of evidence), stride length (MD = 0.05 metres; 95% CI 0.01 to 0.09; P = 0.01; I(2) = 0%; low quality of evidence), but walking distance (MD = 48.9 metres; 95% CI -1.32 to 99.14; P = 0.06; I(2) = 91%; very low quality of evidence) and cadence did not improve (MD = 2.16 steps/minute; 95% CI -0.13 to 4.46; P = 0.07; I(2) = 28%; low quality of evidence) at the end of study. Treadmill training did not increase the risk of patients dropping out from intervention (RD = -0.02; 95% CI -0.06 to 0.02; P = 0.32; I(2) = 13%; moderate quality of evidence). Adverse events were not reported in included studies.

AUTHORS' CONCLUSIONS

This update of our systematic review provides evidence from eighteen trials with moderate to low risk of bias that the use of treadmill training in patients with PD may improve clinically relevant gait parameters such as gait speed and stride length (moderate and low quality of evidence, respectively). This apparent benefit for patients is, however, not supported by all secondary variables (e.g. cadence and walking distance). Comparing physiotherapy and treadmill training against other alternatives in the treatment of gait hypokinesia such as physiotherapy without treadmill training this type of therapy seems to be more beneficial in practice without increased risk. The gain seems small to moderate clinically relevant. However, the results must be interpreted with caution because it is not known how long these improvements may last and some studies used no intervention in the control group and underlie some risk of bias. Additionally the results were heterogenous and we found variations between the trials in patient characteristics, the duration and amount of training, and types of treadmill training applied.

Treadmill training for patients with Parkinson's disease

BACKGROUND

Treadmill training is used in rehabilitation and is described as improving gait parameters of patients with Parkinson's disease.

OBJECTIVES

To assess the effectiveness of treadmill training in improving the gait of patients with Parkinson's disease and the acceptability and safety of this type of therapy.

SEARCH METHODS

We searched the Cochrane Movement Disorders Group Specialised Register (see Review Group details for more information) (last searched September 2014), Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 10), MEDLINE (1950 to September 2014), and EMBASE (1980 to September 2014). We also handsearched relevant conference proceedings, searched trials and research registers, and checked reference lists (last searched September 2014). We contacted trialists, experts and researchers in the field and manufacturers of commercial devices.

SELECTION CRITERIA

We included randomised controlled trials comparing treadmill training with no treadmill training in patients with Parkinson's disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted data. We contacted the trialists for additional information. We analysed the results as mean differences (MDs) for continuous variables and relative risk differences (RD) for dichotomous variables.

MAIN RESULTS

We included 18 trials (6 3 3 participants) in this update of this review. Treadmill training improved gait speed (MD = 0.09 m/s; 95% confidence interval (CI) 0.03 to 0.14; P = 0.001; I(2) = 24%; m oderate quality of evidence), stride length (MD = 0.05 metres; 95% CI 0.01 to 0.09; P = 0.01; I(2) = 0%; l ow quality of e vidence), but walking distance (MD = 48.9 metres; 95% CI -1.32 to 99.14; P = 0.06; I(2) = 91%; very low quality of evidence) and cadence did not improve (MD = 2.16 steps/minute; 95% CI -0.13 to 4.46; P = 0.07; I(2) = 28%; low quality of evidence) at the end of study. Treadmill training did not increase the risk of patients dropping out from intervention (RD = -0.02; 95% CI -0.06 to 0.02; P = 0.32; I(2) = 1 3%; m oderate quality of evidence). Adverse events were not reported in included studies.

AUTHORS' CONCLUSIONS

This update of our systematic review provides evidence from e ighteen trials with moderate to l ow risk of bias that the use of treadmill training in patients with PD may improve clinically relevant gait parameters such as gait speed and stride length (m oderate and low quality of evidence, respectively) . This apparent benefit for patients is, however, not supported by all secondary variables (e.g. cadence and walking distance ). Comparing physiotherapy and treadmill training against other alternatives in the treatment of gait hypokinesia such as physiotherapy without treadmill training this type of therapy seems to be more beneficial in practice without increased risk. The gain seems small to moderate clinically relevant . However, the results must be interpreted with caution because it is not known how long these improvements may last and some s tudies used no intervention in the control group and underlie some risk of bias . Additionally the results were heterogenous and we found variations between the trials in patient characteristics, the duration and amount of training, and types of treadmill training applied.

Partial Body Weight-Supported Treadmill Training in Patients With Parkinson Disease: Impact on Gait and Clinical Manifestation

OBJECTIVE

To evaluate the effect of conventional gait training (CGT) and partial weight-supported treadmill training (PWSTT) on gait and clinical manifestation.

DESIGN

Prospective experimental research design.

SETTING

Hospital.

PARTICIPANTS

Patients with idiopathic Parkinson disease (PD) (N=60; mean age, 58.15±8.7y) on stable dosage of dopaminomimetic drugs were randomly assigned into the 3 following groups (20 patients in each group): (1) nonexercising PD group, (2) CGT group, and (3) PWSTT group.

INTERVENTIONS

The interventions included in the study were CGT and PWSTT. The sessions of the CGT and PWSTT groups were given in patient's self-reported best on status after regular medications. The interventions were given for 30min/d, 4d/wk, for 4 weeks (16 sessions).

MAIN OUTCOME MEASURES

Clinical severity was measured by the Unified Parkinson Disease Rating Scale (UPDRS) and its subscores. Gait was measured by 2 minutes of treadmill walking and the 10-m walk test. Outcome measures were evaluated in their best on status at baseline and after the second and fourth weeks.

RESULTS

Four weeks of CGT and PWSTT gait training showed significant improvements of UPDRS scores, its subscores, and gait performance measures. Moreover, the effects of PWSTT were significantly better than CGT on most measures.

CONCLUSIONS

PWSTT is a promising intervention tool to improve the clinical and gait outcome measures in patients with PD.