Trunk muscle training and early 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.

Back Extensor Strength as a Potential Marker of Frailty Using Propensity Score Matching and Machine Learning

This study assessed the potential of back extensor strength as an alternative marker of frailty. A total of 560 farmers were included. Computed tomography scans measured fat and muscle mass volumes at the mid-L4 vertebral level. Back extensor strength was measured in a seated posture. Multivariate linear regression was used to analyze the associations between back extensor strength and trunk muscle/fat compositions. The participants were divided into two groups based on back extensor strength. Propensity score matching, multivariate logistic regression, and Extreme Gradient Boosting (XGBoost) were employed to evaluate the relationship between Fried's frailty criteria and back extensor strength. Back extensor strength exhibited positive associations with abdominal muscle volume (r = 1.12) as well as back muscle volume (r = 0.89) (p < 0.05). Back extensor strength was linked to more frail status, such as reduced grip strength, walking speed, and frequent self-reported exhaustion. Multivariate logistic regression indicated that back extensor strength was associated with higher frail status (OR = 0.990), and XGBoost analysis identified back extensor strength as the most important predictor (gain = 0.502) for frailty. The prediction models using grip strength produced similar results (OR = 0.869, gain = 0.482). These findings suggested the potential of back extensor strength as an alternative frailty marker.

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.

Objective Measurement of Walking Activity Using Wearable Technologies in People with Parkinson Disease: A Systematic Review

Parkinson’s disease (PD) is a complex neurodegenerative disease with a multitude of disease variations including motor and non-motor symptoms. Quality of life and symptom management may be improved with physical activity. Due to technological advancement, development of small new wearable devices recently emerged and allowed objective measurement of walking activity in daily life. This review was specifically designed to synthesize literature on objective walking activity measurements using wearable devices of patients with PD. Inclusion criteria included patients with a diagnosis of PD and exclusion criteria included studies using animal models or mixed syndromes. Participants were not required to undergo any type of intervention and the studies must have reported at least one output that quantifies daily walking activity. Three databases were systematically searched with no limitation on publication date. Twenty-six studies were eligible and included in the systematic review. The most frequently used device was the ActiGraph GT3X which was used in 10 studies. Duration of monitoring presented a range from 8 h to one year. Nevertheless, 11 studies measured walking activity during a 7-day period. On-body sensor wearing location differed throughout the included studies showing eight positions, with the waist, ankle, and wrist being the most frequently used locations. The main procedures consisted of measurement of walking hours during a 2-day period or more, equipped with a triaxial accelerometer at the dominant hip or ankle. It is also important for further research to take care of different factors such as the population, their pathology, the period, and the environment.

Task-related trunk training on balance, trunk control, pulmonary function and quality of life in patients with Parkinson's disease. A randomised controlled trial

Background/Aims

Stooped posture and ‘en-bloc’ movement of the trunk in people with Parkinson's disease are related to balance issues, pulmonary dysfunction and difficulty in daily tasks. The primary objective of this study was to examine the effects of task-related trunk training on balance in people with Parkinson's disease. The secondary objective was to observe whether trunk control, thoracic rotation range, pulmonary function and quality of life would change for patients with Parkinson's disease after trunk training.

Methods

A total of 32 individuals participated in this randomised controlled trial. They had a mean age of 70.8 years, with a modified Hoehn and Yahr Scale grade of 1.5–3, could take more than six steps in the 360° turn test, were scored as grade I or II on the retropulsion test and had an absence of severe cognitive deficits. Task-related trunk training emphasised the thoracic spine's extension and rotation in prone position on elbows, hands and knees and in kneeling, sitting and standing positions. Standard physiotherapy included breathing exercises, stretching of shoulder and neck muscles, balance and walking training. Both groups practised for 1 hour a day, 3 days a week over 6 weeks. The primary outcome measure was the Mini-Balance Evaluation Systems Test. The secondary outcome measures were the Trunk Control Test, thoracic rotation range of movement, Pulmonary Function Test and Parkinson's Disease Questionnaire-39.

Results

Repeated measure analysis of variance revealed significant group by time interaction for the Mini-Balance Evaluation Systems Test and thoracic rotation range (P<0.05), but not for the pulmonary function test and quality of life measures.

Conclusions

Task-related trunk training appears to be more beneficial in the balance capacity of individuals with Parkinson's disease than standard physiotherapy, but does not have any significant effects for pulmonary function and health-related quality of life.

Objective Measurement of Walking Activity Using Wearable Technologies in People with Parkinson Disease: A Systematic Review Protocol

INTRODUCTION

Parkinson's disease (PD) is a complex neurodegenerative disease with motor and nonmotor symptoms with a multitude of disease variations and severity. Physical activity can improve the management of disease symptoms and increase patients' quality of life. Technological development of small wearable devices allows objective activity measurement such as daily step count.

OBJECTIVE

To synthesize ongoing and past research on objective walking activity measurements using wearable devices in patients with PD.

METHODS

PubMed, Cochrane, Web of Science, and PEDro database are systematically searched with no limitation on publication date. Keywords are relative to (1) the population, (2) the measurement tool, and (3) the measured outcomes. Only full-text English articles published in a peer-reviewed journal will be included. Participants do not have to undergo any type of intervention. Included studies must report an objective measurement of walking activity using wearable devices in PD patients. After an independent screening process done by 2 reviewers, data will be extracted from the articles according to the following 5 set of data: (1) the study metrics, (2) the population characteristics, (3) the measurement tools, (4) the experimental procedure, and (5) the reported outcomes.

RESULTS

The results will contain inter alia summaries of the wearables' specifications, wearing location, and recommendations for feasible methodologies to capture daily walking activity.

DISCUSSION

This review aims to synthesize the evidence of objective walking activity assessment with wearable devices in patients with PD. It will also provide recommendations with regard to device selection and suggest key points when monitoring walking activity in this specific population.

Trunk Exercises Improve Balance in Parkinson Disease: A Phase II Randomized Controlled Trial

BACKGROUND AND PURPOSE

Trunk control is important for maintaining balance; hence, deficient trunk control may contribute to balance problems in people with Parkinson disease (PD). Unfortunately, this deficit is poorly managed with pharmacological therapies, emphasizing the need for alternative therapies for these patients. This randomized controlled trial sought to examine the effects of a 12-week trunk-specific exercise-based intervention on balance in people with PD.

METHODS

Twenty-four people with PD and with a history of falls completed assessments of motor symptom severity, balance confidence, mobility, quality of life, and quiet-standing balance. Participants were then randomized to receive either 12 weeks of exercise or education and reassessed after 12 and 24 weeks.

RESULTS

Linear mixed-models analyses showed no significant changes in clinical outcomes following the intervention. However, during quiet standing, sway area on a foam surface without vision was reduced for the exercise group at 12 (-6.9 ± 3.1 cm; 95% confidence interval [CI] = -13.1 to -0.7; P = 0.029; d = 0.66) and 24 weeks (-7.9 ± 3.1 cm; 95% CI = -14.1 to -1.7; P = 0.013; d = 0.76). Furthermore, the exercise group demonstrated reduced sway variability at 12 (-0.2 ± 0.1 cm; 95% CI = -0.4 to 0.0; P = 0.042; d = 0.62) and 24 weeks in the medial-lateral direction (-0.2 ± 0.1 cm; 95% CI = -0.4 to 0.0; P = 0.043; d = 0.62). No changes in quiet standing balance were recorded for the education group.

DISCUSSION AND CONCLUSIONS

The results of this study suggest that exercise-based interventions targeting trunk strength, endurance, and mobility may be effective for improving quiet-standing balance in people with PD. However, additional research is needed to determine whether these improvements are sufficient to reduce falls risk.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A254).

Social role functioning in Parkinson's disease: A mixed-methods systematic review

OBJECTIVES

Parkinson's disease (PD) is a progressive neurodegenerative disease that often impedes activities of daily living (ADL) and social functioning. Impairment in these areas can alter social roles by interfering with employment status, household management, friendships, and other relationships. Understanding how PD affects social functioning can help clinicians choose management strategies that mitigate these changes.

METHODS

We conducted a mixed-methods systematic review of existing literature on social roles and social functioning in PD. A tailored search strategy in five databases identified 51 full-text reports that fulfilled the inclusion criteria and passed the quality appraisal. We aggregated and analyzed the results from these studies and then created a narrative summary.

RESULTS

Our review demonstrates how PD causes many people to withdraw from their accustomed social roles and experience deficits in corresponding activities. We describe how PD symptoms (eg, tremor, facial masking, and neuropsychiatric symptoms) interfere with relationships (eg, couple, friends, and family) and precipitate earlier departure from the workforce. Additionally, several studies demonstrated that conventional PD therapy has little positive effect on social role functioning.

CONCLUSIONS

Our report presents critical insight into how PD affects social functioning and gives direction to future studies and interventions (eg, couple counseling and recreational activities).

Trunk Exercises Improve Gait Symmetry in Parkinson Disease: A Blind Phase II Randomized Controlled Trial

OBJECTIVE

Deficits in step-to-step symmetry and trunk muscle activations have been linked to falls in Parkinson disease. Given such symptoms are poorly managed with anti-parkinsonian medications, alternate therapies are needed. This blind phase II randomized controlled trial sought to establish whether exercise can improve step-to-step symmetry in Parkinson disease.

DESIGN

Twenty-four Parkinson disease patients with a falls history completed baseline assessments of symptom severity, balance confidence, mobility, and quality of life. Step-to-step symmetry was assessed by deriving harmonic ratios from three-dimensional accelerations collected for the head and trunk. Patients were randomly assigned to either 12 wks of exercise and falls prevention education or falls prevention education only. Both groups repeated the baseline tests 12 and 24 wks after the initial assessment. The Australian and New Zealand Clinical Trials Registry number is ACTRN12613001175763.

RESULTS

At 12 wks, the exercise group had statistically significant and clinically relevant improvements in anterior-posterior step-to-step trunk symmetry. In contrast, the education group recorded statistically significant and clinically meaningful reductions in medial-lateral and vertical step-to-step trunk symmetry at 12 wks.

CONCLUSIONS

Given that step-to-step symmetry improved for the exercise group and declined for the education group after intervention, active interventions seem more suited to increasing independence and quality of life for people with Parkinson disease.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to do the following: (1) Describe the effect deficits in trunk muscle function have on gait in individuals with Parkinson disease; (2) Identify the benefits of targeted trunk exercises on step-to-step symmetry; and (3) Discuss the benefits of improving step-to-step symmetry in individuals with Parkinson disease.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Auditing the Physical Activity and Parkinson Disease Literature Using the Behavioral Epidemiologic Framework

Motor and nonmotor symptoms associated with Parkinson disease place individuals at greater risk of sedentary behaviors and comorbidities. Physical activity is one modifiable means of improving health and reducing the risk of morbidity. We applied a behavioral framework to classify existing research on physical activity and Parkinson disease to describe the current evolution and inform knowledge gaps in this area. Research placed in phase 1 establishes links between physical activity and health-related outcomes; phase 2 develops approaches to quantify physical activity behavior; phase 3 identifies factors associated with implementation of physical activity behaviors; phase 4 assesses the effectiveness of interventions to promote activity; and phase 5 disseminates evidence-based recommendations. Peer-reviewed literature was identified by searching PubMed, Google Scholar, and EBSCO-host. We initially identified 287 potential articles. After further review, we excluded 109 articles, leaving 178 included articles. Of these, 75.84% were categorized into phase 1 (n = 135), 10.11% in phase 2 (n = 18), 9.55% into phase 3 (n = 17), 3.37% into phase 4 (n = 6), and 1.12% into phase 5 (n = 2). By applying the behavioral framework to the physical activity literature for people with Parkinson disease, we suggest this area of research is nascent with more than 75% of the literature in phase 1.

LEVEL OF EVIDENCE

III.

The Effects of Physical Activity in Parkinson's Disease: A Review

BACKGROUND

Physical activity (PA) is increasingly advocated as an adjunct intervention for individuals with Parkinson's disease (PD). However, the specific benefits of PA on the wide variety of impairments observed in patients with PD has yet to be clearly identified.

OBJECTIVE

Highlight health parameters that are most likely to improve as a result of PA interventions in patients with PD.

METHODS

We compiled results obtained from studies examining a PA intervention in patients with PD and who provided statistical analyses of their results. 868 outcome measures were extracted from 106 papers published from 1981 to 2015. The results were classified as having a statistically significant positive effect or no effect. Then, outcome measures were grouped into four main categories and further divided into sub-categories.

RESULTS

Our review shows that PA seems most effective in improving Physical capacities and Physical and cognitive functional capacities. On the other hand, PA seems less efficient at improving Clinical symptoms of PD and Psychosocial aspects of life, with only 50% or less of results reporting positive effects. The impact of PA on Cognitive functions and Depression also appears weaker, but few studies have examined these outcomes.

DISCUSSION

Our results indicate that PA interventions have a positive impact on physical capacities and functional capacities. However, the effect of PA on symptoms of the disease and psychosocial aspects of life are moderate and show more variability. This review also highlights the need for more research on the effects of PA on cognitive functions, depression as well as specific symptoms of PD.

Progressive resistance training in Parkinson's disease: a systematic review and meta-analysis

OBJECTIVES

To investigate if there is evidence on effectiveness of progressive resistance training in rehabilitation of Parkinson disease.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Central, Medline, Embase, Cinahl, Web of Science, Pedro until May 2014. Randomised controlled or controlled clinical trials. The methodological quality of studies was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

DATA SYNTHESIS

random effects meta-analysis with test for heterogeneity using the I² and pooled estimate as the raw mean difference.

PARTICIPANTS

Adults with primary/idiopathic Parkinson's disease of any severity, excluding other concurrent neurological condition.

INTERVENTIONS

Progressive resistance training defined as training consisting of a small number of repetitions until fatigue, allowing sufficient rest between exercises for recovery, and increasing the resistance as the ability to generate force improves.

COMPARISON

Progressive resistance training versus no treatment, placebo or other treatment in randomised controlled or controlled clinical trials.

PRIMARY AND SECONDARY OUTCOME MEASURES

Any outcome.

RESULTS

Of 516 records, 12 were considered relevant. Nine of them had low risk of bias. All studies were randomised controlled trials conducted on small samples with none or 1 month follow-up after the end of intervention. Of them, six were included in quantitative analysis. Pooled effect sizes of meta-analyses on fast and comfortable walking speed, the 6 min walking test, Timed Up and Go test and maximal oxygen consumption were below the level of minimal clinical significance.

CONCLUSIONS

There is so far no evidence on the superiority of progressive resistance training compared with other physical training to support the use of this technique in rehabilitation of Parkinson's disease.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2014:CRD42014009844.

Effects of Resistance Training on Measures of Muscular Strength in People with Parkinson's Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to determine the overall effect of resistance training (RT) on measures of muscular strength in people with Parkinson's disease (PD).

METHODS

Controlled trials with parallel-group-design were identified from computerized literature searching and citation tracking performed until August 2014. Two reviewers independently screened for eligibility and assessed the quality of the studies using the Cochrane risk-of-bias-tool. For each study, mean differences (MD) or standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for continuous outcomes based on between-group comparisons using post-intervention data. Subgroup analysis was conducted based on differences in study design.

RESULTS

Nine studies met the inclusion criteria; all had a moderate to high risk of bias. Pooled data showed that knee extension, knee flexion and leg press strength were significantly greater in PD patients who undertook RT compared to control groups with or without interventions. Subgroups were: RT vs. control-without-intervention, RT vs. control-with-intervention, RT-with-other-form-of-exercise vs. control-without-intervention, RT-with-other-form-of-exercise vs. control-with-intervention. Pooled subgroup analysis showed that RT combined with aerobic/balance/stretching exercise resulted in significantly greater knee extension, knee flexion and leg press strength compared with no-intervention. Compared to treadmill or balance exercise it resulted in greater knee flexion, but not knee extension or leg press strength. RT alone resulted in greater knee extension and flexion strength compared to stretching, but not in greater leg press strength compared to no-intervention.

DISCUSSION

Overall, the current evidence suggests that exercise interventions that contain RT may be effective in improving muscular strength in people with PD compared with no exercise. However, depending on muscle group and/or training dose, RT may not be superior to other exercise types. Interventions which combine RT with other exercise may be most effective. Findings should be interpreted with caution due to the relatively high risk of bias of most studies.

Trunk muscle exercises as a means of improving postural stability in people with Parkinson's disease: a protocol for a randomised controlled trial

INTRODUCTION

Exercise has been shown to improve clinical measures of strength, balance and mobility, and in some cases, has improved symptoms of tremor and rigidity in people with Parkinson's disease (PD). However, to date, no research has examined whether improvements in trunk control can remedy deficits in dynamic postural stability in this population. The proposed randomised controlled trial aims to establish whether a 12-week exercise programme aimed at improving dynamic postural stability in people with PD; (1) is more effective than education; (2) is more effective when training frequency is increased; and (3) provides greater long-term benefits than education.

METHODS/DESIGN

Forty-five community-dwelling individuals diagnosed with idiopathic PD with a falls history will be recruited. Participants will complete baseline assessments including tests of cognition, vision, disease severity, fear of falling, mobility and quality of life. Additionally, participants will complete a series of standing balance tasks to evaluate static postural stability, while dynamic postural control will be measured during walking using head and trunk-mounted three-dimensional accelerometers. Following baseline testing, participants will be randomly-assigned to one of three intervention groups, who will receive either exercise once per week, exercise 3 days/week, or education. Participants will repeat the same battery of tests conducted at baseline after the 12-week intervention and again following a further 12-week sustainability period.

DISCUSSION

This study has the potential to show that low-intensity and progressive trunk exercises can provide a non-invasive and effective means for maintaining or improving postural stability for people with PD. Importantly, if the programme is noted to be effective, it could be easily performed by patients within their home environment or under the guidance of available allied health professionals.

TRIAL REGISTRATION NUMBER

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613001175763).

Physiotherapy versus placebo or no intervention in Parkinson's disease

BACKGROUND

Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. Physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety, and well-being, thereby enhancing quality of life.

OBJECTIVES

To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.

SEARCH METHODS

We identified relevant trials by conducting electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, and by handsearching major journals, abstract books, conference proceedings, and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012.

SELECTION CRITERIA

Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance, and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions.

MAIN RESULTS

We identified 39 trials with 1827 participants. We considered the trials to be at a mixed risk of bias as the result of unreported allocation concealment and probable detection bias. Compared with no intervention, physiotherapy significantly improved the gait outcomes of speed (mean difference 0.04 m/s, 95% confidence interval (CI) 0.02 to 0.06, P = 0.0002); two- or six-minute walk test (13.37 m, 95% CI 0.55 to 26.20, P = 0.04) and Freezing of Gait questionnaire (-1.41, 95% CI -2.63 to -0.19, P = 0.02); functional mobility and balance outcomes of Timed Up & Go test (-0.63 s, 95% CI -1.05 to -0.21, P = 0.003), Functional Reach Test (2.16 cm, 95% CI 0.89 to 3.43, P = 0.0008), and Berg Balance Scale (3.71 points, 95% CI 2.30 to 5.11, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total -6.15 points, 95% CI-8.57 to -3.73, P < 0.00001; activities of daily living: -1.36, 95% CI -2.41 to -0.30, P = 0.01; and motor: -5.01, 95% CI -6.30 to -3.72, P < 0.00001). No difference between arms was noted in falls (Falls Efficacy Scale: -1.91 points, 95% CI -4.76 to 0.94, P = 0.19) or patient-rated quality of life (PDQ-39 Summary Index: -0.38 points, 95% CI -2.58 to 1.81, P = 0.73). One study reported that adverse events were rare; no other studies reported data on this outcome. Indirect comparisons of the different physiotherapy interventions revealed no evidence that the treatment effect differed across physiotherapy interventions for any of the outcomes assessed.

AUTHORS' CONCLUSIONS

Benefit for physiotherapy was found in most outcomes over the short term (i.e. < 3 months) but was significant only for speed, two- or six-minute walk test, Freezing of Gait questionnaire, Timed Up & Go, Functional Reach Test, Berg Balance Scale, and clinician-rated UPDRS. Most of the observed differences between treatments were small. However, for some outcomes (e.g. speed, Berg Balance Scale, UPDRS), the differences observed were at, or approaching, what are considered minimal clinically important changes. These benefits should be interpreted with caution because the quality of most of the included trials was not high. Variation in measurements of outcome between studies meant that our analyses include a small proportion of the participants recruited.This review illustrates that a wide range of approaches are employed by physiotherapists to treat patients with PD. However, no evidence of differences in treatment effect was noted between the different types of physiotherapy interventions being used, although this was based on indirect comparisons. A consensus menu of 'best practice' physiotherapy is needed, as are large, well-designed randomised controlled trials undertaken to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.

Physiotherapy versus placebo or no intervention in Parkinson's disease

BACKGROUND

Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and well-being, thereby enhancing quality of life.

OBJECTIVES

To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.

SEARCH METHODS

We identified relevant trials by electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to end of December 2010.

SELECTION CRITERIA

Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions.

MAIN RESULTS

We identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s, 95% confidence interval (CI): 0.02 to 0.07, P = 0.0002), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). There was no difference between arms in falls or patient-rated quality of life. Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.

AUTHORS' CONCLUSIONS

Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.

Physiotherapy versus placebo or no intervention in Parkinson's disease

BACKGROUND

Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and well-being, thereby enhancing quality of life.

OBJECTIVES

To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.

SEARCH METHODS

We identified relevant trials by electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to end of December 2010.

SELECTION CRITERIA

Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions.

MAIN RESULTS

We identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s, 95% confidence interval (CI): 0.02 to 0.07, P = 0.0002), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). There was no difference between arms in falls or patient-rated quality of life. Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.

AUTHORS' CONCLUSIONS

Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.

Themes associated with exercise adherence in persons with Parkinson's disease: a qualitative study

ABSTRACT The purpose of this study was to examine motivators important to exercise adherence in a group of older adults with Parkinson's disease (PD). Four participants with PD completed a 6-week hydrotherapy program, followed by participation in a focus group along with their caregivers (n = 4) to examine motivators that were important to exercise adherence. A semi-structured focus group was transcribed verbatim and analyzed using content analysis to identify common patterns and themes. Multiple themes were found that were important to exercise adherence. Constant reassurance and support from the exercise leader was a primary theme for remaining enrolled in an exercise program. Exercising in a group environment and social interaction with other persons with PD were also the themes. Perceived changes in physical ability increased participants' confidence and motivation to continue to exercise. The findings suggest that the perceived needs of PD exercise participants can be influenced and addressed by exercise leaders, provide opportunities to improve physical function, and support social interaction. Future exercise programs should be designed to provide a venue where the symptoms of PD are not a deterrent to exercise participation.

Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence, and adverse events in clinical trials

There is research evidence that exercise and motor training are beneficial for people with Parkinson's disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis

Parkinson's disease (PD) is a neurodegenerative disorder affecting the physical, psychological, social, and functional status of individuals. Exercise programs may be an effective strategy to delay or reverse functional decline for people with PD and a large body of empirical evidence has emerged in recent years. The objective is to systematically review randomized controlled trials (RCTs) reporting on the effectiveness of exercise interventions on outcomes (physical, psychological or social functioning, or quality of life) for people with PD. RCTs meeting the inclusion criteria were identified by systematic searching of electronic databases. Key data were extracted by two independent researchers. A mixed methods approach was undertaken using narrative, vote counting, and random effects meta-analysis methods. Fourteen RCTs were included and the methodological quality of most studies was moderate. Evidence supported exercise as being beneficial with regards to physical functioning, health-related quality of life, strength, balance and gait speed for people with PD. There was insufficient evidence support or refute the value of exercise in reducing falls or depression. This review found evidence of the potential benefits of exercise for people with PD, although further good quality research is needed. Questions remain around the optimal content of exercise interventions (dosing, component exercises) at different stages of the disease.

Validity of the Trunk Impairment Scale as a Measure of Trunk Performance in People With Parkinson’s Disease

OBJECTIVE

To evaluate construct validity of the Trunk Impairment Scale (TIS) as a measure of trunk performance in Parkinson's disease (PD).

DESIGN

A cross-sectional study of PD patients and healthy subjects.

SETTING

University rehabilitation research unit.

PARTICIPANTS

Twenty-six PD patients (Hoehn and Yahr stages 2-4) and 26 healthy subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The TIS and its subscales; static and dynamic sitting balance and trunk coordination.

RESULTS

Compared with healthy controls, PD patients showed significantly lower scores on the total TIS, static sitting balance, and coordination subscale. Healthy subjects scored significantly better on the total TIS and coordination subscale compared with patients in the early stage of PD. Patients with PD in the early stage scored significantly higher for the total TIS as well as static and dynamic sitting balance in comparison with PD patients in a later stage. Forward stepwise multiple linear regression analysis showed that trunk impairment in PD patients was significantly related to a combination of older age and a higher score on part III of the Unified Parkinson's Disease Rating Scale, which assesses motor impairments.

CONCLUSIONS

Early detection of trunk deficits and the significant relation with PD severity advocates further evaluation and use of the TIS in PD.

Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research

Physical therapy is often prescribed in Parkinson's disease. To facilitate the uniformity and efficacy of this intervention, we analyzed current evidence and developed practice recommendations. We carried out an evidence-based literature review. The results were supplemented with clinical expertise and patient values and translated into practice recommendations, developed according to international standards for guideline development. A systematic literature search yielded 6 systematic reviews and 23 randomized controlled trials of moderate methodological quality with sufficient data. Six specific core areas for physical therapy were identified: transfers, posture, reaching and grasping, balance, gait, and physical capacity. We extracted four specific treatment recommendations that were based on evidence from more than two controlled trials: cueing strategies to improve gait; cognitive movement strategies to improve transfers; exercises to improve balance; and training of joint mobility and muscle power to improve physical capacity. These practice recommendations provide a basis for current physical therapy in Parkinson's disease in everyday clinical practice, as well as for future research in this field.

A systematic review of the Human Activity Profile

OBJECTIVE

To review the measurement properties (reliability, validity, responsiveness) of the Human Activity Profile (HAP), a self-report measure of energy expenditure or physical fitness.

DATA SOURCES

MEDLINE, CINAHL and EMBASE were searched up to September 2005 and the reference lists of included studies were checked for additional relevant studies.

REVIEW METHOD

Studies were included that reported Human Activity Profile scores, test-retest reliability, correlations with other measures, or responsiveness (sensitivity to change). Of 83 potentially relevant articles, 39 articles were included plus the test manual. Two independent reviewers extracted data from the included studies.

RESULTS

The Human Activity Profile has been used to evaluate physical activity in a wide variety of clinical populations and in healthy individuals. The change in score required to be 90% confident that change is beyond measurement error was estimated to be 7.8 for the Maximum Activity Score and 6.8 for the Adjusted Activity Score. The construct validity of the Human Activity Profile was supported by a large number of studies, although evidence for criterion validity was limited to four studies. No studies have investigated a priori the responsiveness or minimum clinically important difference of the Human Activity Profile.

CONCLUSION

The Human Activity Profile appears to be a useful indicator of physical activity levels in people with chronic pain, arthritis, renal failure, various neurological and cardiorespiratory conditions, as well as in healthy older people.

Is physical exercise beneficial for persons with Parkinson's disease?

OBJECTIVE

To review existing studies evaluating the effectiveness of physical exercise on mortality, strength, balance, mobility, and activities of daily living (ADL) for sufferers of Parkinson's disease (PD).

DATA SOURCES

The following databases were searched (1) Cochrane Database of Systematic Reviews, (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (3) PubMed and (4) Medline/NARIC (National Rehabilitation Information Center) using combinations of key words Parkinson's disease and physical exercise. Only articles written in English were included. References cited were also examined.

STUDY SELECTION

Studies were eligible if (1) only patients with PD were included in the intervention study (there were many studies that evaluated the benefits of exercise after stroke, cardiac arrest, sports injuries, surgery, and arthritis, but only a few for patients with PD), (2) the intervention included some form of physical or therapeutic exercise, (3) the effects of the physical exercise were evaluated, and (4) the studies were published in a refereed journal. Because few studies were found that dealt with PD patients exclusively, all studies that evaluated the effectiveness of physical exercise for only PD patients were included. Seven studies met our criteria and were selected. Three of the selected studies were randomized controlled studies, 1 was an open trial, and the other 3 relied on patients' own assessments.

DATA SYNTHESIS

Outcomes in the studies were measured in terms of physical improvements in patients with PD, such as improved axial rotation, functional reach, flexibility, balance, muscle strength, short-step gait, and mobility. All studies reviewed show that exercise improves overall performance in PD patients. Improvements were measured using standardized tests and other measurement scales.

CONCLUSIONS

The results of the present research synthesis support the hypothesis that patients with PD improve their physical performance and activities of daily living through exercise. Future studies should include the development of standardized exercise programs specific for problems associated with PD as well as standardized testing methods for measuring improvements in PD patients. There is also a need for longer term studies (over 1 year) to assess if improvements achieved during the intervention stage are retained long term.

Rehabilitation for Parkinson's disease: a systematic review of available evidence

OBJECTIVE

To systematically review the available evidence on the effectiveness of nonpharmacological rehabilitation interventions for people with Parkinson's disease, and identify future research needs.

DESIGN

Electronic searches of four databases (CINAHL, Cochrane Library, MEDLINE, PsychLIT) 1980-2002; examination of reference lists of relevant papers. Controlled trials and observational studies were included. Data extraction and quality assessment of papers by two independent reviewers. A narrative review.

SETTING

Rehabilitation interventions delivered either in subjects' own homes, or in clinical settings as outpatients.

SUBJECTS

Community-living adults with Parkinson's disease.

INTERVENTIONS

Physiotherapy, occupational therapy, speech and language therapy, psychological counselling and support, and education.

MAIN MEASURES

A range of outcomes: mobility, functional status, speech, swallowing, psychological well-being, as determined by the studies included in the review.

RESULTS

Forty-four different studies (reported in 51 papers) were included (25 physiotherapy, 4 occupational therapy, 10 speech and language therapy, 3 psychological counselling, 1 educational, 1 multidisciplinary). All studies, except one, reported improvements on at least one outcome measure.

CONCLUSIONS

Findings may reflect publication bias, but suggest interventions can affect patients' lives for the better in a variety of ways. It is difficult to interpret the clinical importance of statistically significant improvements reported in most studies. There is a need for methodologically more robust research with meaningful follow-up periods, designed in a manner that separates specific and nonspecific effects. Cost-effectiveness evidence is required to provide clear guidance on service extensions.

Exercise and aging

There is increasing evidence that the black box we have referred to as"biologic aging" is composed of genetic factors and many types of environmental exposures. Some of the most potentially modifiable elements of this syndrome are those attributable to disuse or insufficient exposure to certain kinds or intensities of physical stressors during the course of the life span. Beneficial adaptations to exercise once thought restricted to genetically endowed master athletes now are seen to occur just as predictably in frail elders with chronic disease, opening the door to vastly improved physical function and associated health benefits. Knowledge of the benefits of physical activity, however well substantiated, may be necessary, but it is not sufficient to change either physician-prescribing habits or the likelihood of adoption and long-term adherence to exercise on the part of patients. Ultimately, the penetration of an exercise prescription to optimize aging into the most inactive cohorts in the community,who have the most to gain from increases in levels of physical activity and fitness, will depend on a combination of clear evidence-based guidelines coupled with health professional training and behavioral programs tailored to age-specific barriers and motivational factors.

Prediction of outcome of physiotherapy in advanced Parkinson's disease

OBJECTIVE

Prediction of the effect of a home physiotherapy intervention on the basis of four clinical characteristics of patients with advanced Parkinson's disease.

DESIGN

A repeated measures design comparing six weeks without treatment with six weeks of physiotherapy and a follow-up of 12 weeks.

SUBJECTS

Persons with Parkinson's disease without dementia and suffering from considerable functional disability.

INTERVENTION

Community physiotherapists treated patients in the home situation three times a week teaching cueing and conscious movement control for walking and carrying out transfers in and out of beds and chairs.

MAIN OUTCOME MEASURES

Mental status, disease severity, age and mood were included as predictor variables. A new functional scale developed as part of a previous study was used as the dependent variable administered in both the hospital and the home to determine whether the outcome generalized from the learning to a different environment.

RESULTS

Only disease severity was a negative predictor of treatment outcome at home. In the hospital setting none of the factors predicted the immediate effect of treatment but cognitive ability and age were determinants of whether the treatment effects were maintained in the long term.

CONCLUSIONS

Using cueing and cognitive strategies benefited younger and older patients with Parkinson's disease alike. However, the findings indicate targeting of treatment at patients with milder disease severity and providing follow-up treatment for older and cognitively less able patients.

Systematic review of paramedical therapies for Parkinson's disease

We evaluated the efficacy of physiotherapy, occupational therapy, and speech and language therapy in Parkinson's disease by synthesizing six Cochrane systematic reviews. All randomised, controlled trials examining the efficacy of a paramedical therapy versus control intervention and all those comparing the efficacy of two forms of active therapy in Parkinson's disease were included. Trials were identified by searching biomedical databases, reference lists, hand searching, and contacting investigators. The main outcome measures were quality of life, speech intelligibility, activities of daily living, and individual measures of motor and speech impairment. We identified 16 physiotherapy randomised controlled trials (399 patients), two occupational therapy trials (84 patients), and five speech and language therapy for dysarthria trials (154 patients). None of these studies examined nonpharmacological swallowing therapy for dysphagia. We were unable to perform meta-analysis of the results because the trials used heterogeneous therapy methods and outcome measures. The trials also had marked methodological flaws that could have introduced bias. In summary, we failed to find conclusive evidence of benefit for any form of paramedical therapy sufficient to recommend them in routine clinical practice. However, this lack of evidence is not proof of a lack of effect. Further large pragmatic randomised controlled trials are required to determine the effectiveness of paramedical therapies in Parkinson's disease.

Exercise to prevent and treat functional disability

There are myriad ways in which optimal levels of physical activity over the course of the life span could potentially contribute to the prevention of functional disability in old age. These include direct effects of exercise to maximize physiologic capacity and prevent or delay the onset of disability-related conditions and more indirect effects, such as the modulation of psychosocial factors important in the expression of disability. Epidemiologic studies strongly suggest that functional disability is inversely related to physical activity level or physical fitness in various domains. Experimental studies confirm the benefits of exercise on correlates of disability, such as impairments of muscle strength or performance-based tests of functional limitations. However, the evidence that exercise can actually prevent disability in the long-term is not yet established by data from randomized clinical trials in the general population. Secondary prevention of disability in frail elders has been shown in a few trials. The available evidence, however, suggests that a rational exercise prescription for the prevention and treatment of disability at this time should include promotion of a physically active lifestyle and specific exercises targeting aerobic capacity, strength, and balance. Differential emphasis on specific elements of this prescription may be necessary and appropriate, depending on the etiology of the disability in specific cohorts, severity of physical impairments and functional limitations, and other individual characteristics relevant to exercise feasibility, safety, and efficacy.

The effect of a home physiotherapy program for persons with Parkinson's disease

The purpose of this study was to evaluate the effect of a home physiotherapy program for persons with Parkinson's disease. Thirty-three patients took part in the study using a within-subject controlled design. Functional activities including walking and carrying out transfers were measured at home and in the hospital before and after a 6-week baseline period, after 6 weeks home physiotherapy and after 3 months follow-up. Spatiotemporal and plantar force variables of gait were determined with video and pododynography. Treatment provided by community physiotherapists consisted of teaching cueing and conscious movement control 3 times a week. The study revealed that patients had significantly higher scores on a functional activity scale after treatment in the home setting and to a lesser degree in hospital, a result, which was partly sustained at follow-up. However, duration of the transfer movements, spatiotemporal and plantar force variables were not significantly improved except for stride length. The results support application and development of the treatment concept and highlight that physiotherapy aimed at improving function in Parkinson's disease is best provided in the home situation.

Physiotherapy for patients with Parkinson's Disease: a comparison of techniques

BACKGROUND

Despite optimal medical and surgical therapies for Parkinson's disease, patients develop progressive disability. The role of the physiotherapist is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person.

OBJECTIVES

To compare the efficacy and effectiveness of physiotherapy with placebo or no interventions in patients with Parkinson's disease.

SEARCH STRATEGY

Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, ISI-SCI, AMED, MANTIS, REHABDATA, REHADAT, GEROLIT, Pascal, LILACS, MedCarib, JICST-EPlus, AIM, IMEMR, SIGLE, ISI-ISTP, DISSABS, Conference Papers Index, Aslib Index to Theses, the Cochrane Controlled Trials Register, the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR; and examination of the reference lists of identified studies and other reviews.

SELECTION CRITERIA

Only randomised controlled trials (RCT) were included, however those trials that allowed quasi-random methods of allocation were allowed.

DATA COLLECTION AND ANALYSIS

Data was abstracted independently by KD and DJ and differences settled by discussion.

MAIN RESULTS

Eleven trials were identified with 280 patients. Eight trials did not have adequate placebo treatments, all used small numbers of patients and the method of randomisation and concealment of allocation was good in only four trials. These methodological problems could potentially lead to bias from a number of sources. Although ten of the trials claimed a positive effect from physiotherapy, few outcomes measured were statistically significant. Walking velocity was measured in four trials and increased significantly in two of them. Stride length was the only other outcome measured in more than one trial, it was significantly improved in two trials. Five other outcomes improved significantly in individual studies, but eight other outcomes did not improve significantly.

REVIEWER'S CONCLUSIONS

Considering the methodological flaws in many of the studies, the small number of patients examined, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of physiotherapy in Parkinson's disease. The studies illustrate that a wide range of approaches are being employed by physiotherapists to treat Parkinson's disease. This was confirmed by the UK survey of physiotherapists. There is a need to develop a consensus as to 'best-practice'. Large well designed placebo-controlled RCTs are then needed to demonstrate the efficacy and effectiveness of 'best practice' physiotherapy in Parkinson's disease. The stage of the disease at which the physiotherapy is given should be specified at the outset. Outcome measures with particular relevance to patients, carers, physiotherapists and physicians should be chosen and the patients monitored for at least six months to determine the duration of any beneficial effects. The trials should be reported according to CONSORT guidelines.

Movement Disorders in People With Parkinson Disease: A Model for Physical Therapy

People who are diagnosed with idiopathic Parkinson disease (PD) experience movement disorders that, if not managed, can lead to considerable disability. The premise of this perspective is that physical therapy for people with PD relies on clinicians having: (1) up-to-date knowledge of the pathogenesis of movement disorders, (2) the ability to recognize common movement disorders in people with PD, (3) the ability to implement a basic management plan according to a person's stage of disability, and (4) problem-solving skills that enable treatment plans to be tailored to individual needs. This article will present a model of physical therapy management for people with idiopathic PD based on contemporary knowledge of the pathogenesis of movement disorders in basal ganglia disease as well as a review of the evidence for physical therapy interventions. The model advocates a task-specific approach to training, with emphasis on treating people with PD-related movement disorders such as hypokinesia and postural instability within the context of functional tasks of everyday living such as walking, turning over in bed, and manipulating objects. The effects of medication, cognitive impairment, the environment, and coexisting medical conditions are also taken into consideration. An argument is put forward that clinicians need to identify core elements of physical therapy training that apply to all people with PD as well as elements specific to the needs of each individual. A case history is used to illustrate how physical therapy treatment is regularly reviewed and adjusted according to the changing constellation of movement disorders that present as the disease progresses.