Physiotherapy for Parkinson's disease: a comparison of techniques
Abstract
Background
Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is 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 wellbeing, thereby enhancing quality of life. Trials have shown that physiotherapy has short‐term benefits in PD. However, which physiotherapy intervention is most effective remains unclear.
Objectives
To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD.
Search methods
Relevant trials were identified by electronic searches of numerous literature databases (for example 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 the end of January 2012.
Selection criteria
Randomised controlled trials of one physiotherapy intervention versus another physiotherapy intervention in patients with PD.
Data collection and analysis
Data were abstracted independently from each paper by two authors. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts.
Main results
A total of 43 trials were identified with 1673 participants. All trials used small patient numbers (average trial size of 39 participants); the methods of randomisation and concealment of allocation were poor or not stated in most trials. Blinded assessors were used in just over half of the trials and only 10 stated that they used intention‐to‐treat analysis.
A wide variety of validated and customised outcome measures were used to assess the effectiveness of physiotherapy interventions. The most frequently reported physiotherapy outcomes were gait speed and timed up and go, in 19 and 15 trials respectively. Only five of the 43 trials reported data on falls (12%). The motor subscales of the Unified Parkinson’s Disease Rating Scale and Parkinson’s Disease Questionnaire‐39 were the most commonly reported clinician‐rated disability and patient‐rated quality of life outcome measures, used in 22 and 13 trials respectively. The content and delivery of the physiotherapy interventions varied widely in the trials included within this review, so no quantitative meta‐analysis could be performed.
Authors' conclusions
Considering the small number of participants examined, the methodological flaws in many of the studies, the possibility of publication bias, and the variety of interventions, formal comparison of the different physiotherapy techniques could not be performed. There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another in PD.
This review shows that a wide range of physiotherapy interventions to treat PD have been tested . There is a need for more specific trials with improved treatment strategies to underpin the most appropriate choice of physiotherapy intervention and the outcomes measured.
PICOs
Plain language summary
Physiotherapy for the treatment of Parkinson's disease
In spite of various medical and surgical treatments for Parkinson's disease (PD) patients gradually develop significant physical problems. Physiotherapists aim to enable people with PD to maintain their maximum level of mobility, activity and independence through the provision of the appropriate treatment. A range of approaches to movement rehabilitation are used, which aim to enhance quality of life by maximising physical ability and minimising secondary complications over the whole course of the disease. Evidence has shown that physiotherapy has short‐term benefits in PD, however which approach of physiotherapy is most effective remains unclear.
Only randomised controlled trials were included in this review. These were studies where a group of participants were given one physiotherapy intervention and were compared with another group who received a different physiotherapy intervention. The participants were assigned to a group in a random fashion to reduce the potential for bias.
A total of 43 randomised trials involving 1673 participants (average trial size of just 39 participants) were identified as suitable for this review. The trials assessed various physiotherapy interventions, so they were grouped according to the type of intervention being used (general physiotherapy, exercise, treadmill training, cueing, dance or martial arts). However, despite this grouping, the physiotherapy interventions delivered and the outcomes assessed varied so much that the results of the individual trials could not be combined.
This review highlights that a wide range of different physiotherapy techniques have been tested to treat PD. Considering the small number of participants, the wide variety of physiotherapy interventions and the outcomes assessed, there is insufficient evidence to support the use of one approach of physiotherapy intervention over another for the treatment of PD.
Authors' conclusions
Background
Parkinson’s disease (PD) is a complex neurodegenerative disorder (Rubenis 2007) with wide reaching implications for patients and their families. Whilst disability can occur at all stages of the disease (Deane 2001a), PD is progressive in nature. Patients face increased difficulties with activities of daily living (ADL) (Kwakkel 2007) and mobility such as gait, transfers, balance and posture (Keus 2007). Ultimately this leads to decreased independence, inactivity and social isolation (Keus 2007), resulting in reduced quality of life (Schrag 2000).
The management of PD has traditionally centred on drug therapy with levodopa viewed as the 'gold standard' treatment (Rascol 2002). However, even with optimal medical management, patients with PD still experience a deterioration of body function, daily activities and participation (Nijkrake 2007). For this reason there has been increasing support for the inclusion of rehabilitation therapies as an adjuvant to pharmacological and neurosurgical treatment (Gage 2004; Nijkrake 2007) and a call for the move towards multidisciplinary management of this multidimensional condition (Robertson 2003; Rubenis 2007).
The physiotherapist is a member of the multidisciplinary team (Robertson 2008; Rubenis 2007) and strives to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person (Deane 2001a; Plant 2000). Physiotherapy for PD focuses on transfers, posture, upper limb function, balance (and falls), gait, physical capacity and (in)activity utilising cueing strategies, cognitive movement strategies and exercise to optimise the patient’s independence, safety and wellbeing, thereby enhancing quality of life (Keus 2004; Keus 2007).
Referral rates to physiotherapy for people with PD have historically been low (Mutch 1986; Yarrow 1999). However, in recent years the number of referrals has increased, with a survey by Parkinson’s UK in 2008 reporting that 54% of the 13,000 members surveyed had seen a physiotherapist, compared with 27% in a survey undertaken in 1998 (PDS 2008; Yarrow 1999). This rise in referrals may be attributed to two factors. Firstly, guidelines such as those published by the National Institute for Health and Clinical Excellence (NICE) (NICE CG35 2006) recommend that physiotherapy be made available throughout all stages of the disease, raising the profile of the intervention. This has been further supported by the publication of Dutch physiotherapy guidelines (Keus 2004) (updated guidelines were due for publication in 2013), which provide specific information for physiotherapists involved in the management of PD. Secondly, there has been a substantial increase in the number of trials completed over the last decade (particularly in the last five years), offering supportive evidence for the inclusion of physiotherapy in the management of PD (Keus 2009).
A recent Cochrane review (Tomlinson 2012) assessed the effectiveness of physiotherapy intervention versus no physiotherapy intervention in patients with PD. The review provided evidence for the short‐term benefit (< three months) of physiotherapy intervention in the treatment of PD. Further, it suggested that there was no difference in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. This now needs to be confirmed by examining head‐to‐head trials of physiotherapy interventions. This would be of interest to both clinicians and patients so that appropriate physiotherapy interventions which provide greater benefit can be delivered to PD patients (Tomlinson 2012).
The present Cochrane review was first published in 2001, and included only seven randomised controlled trials with a total of 142 participants (Deane 2001b). The methods of physiotherapy varied so widely across the trials that the data could not be combined. This, along with the presence of methodological flaws, small sample sizes, and the possibility of publication bias, led Deane et al to conclude that there was insufficient evidence to support or refute the efficacy of any given approach of physiotherapy over another in PD (Deane 2001b). This review updates the previous Cochrane review. It aims to compare the effectiveness of one approach of physiotherapy intervention versus another approach of physiotherapy intervention in patients with PD.
Objectives
To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD.
Methods
Criteria for considering studies for this review
Types of studies
All randomised controlled trials (including the first phase of cross‐over trials) comparing a physiotherapy intervention with another physiotherapy intervention were considered for inclusion in the review. Only trials that implemented random methods of treatment allocation were included.
Types of participants
Participants with a diagnosis of PD (as defined by the authors of the studies).
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PD of any disease stage (i.e. early or diagnostic, maintenance, or complex phase).
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Any duration of PD.
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All ages.
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Any drug therapy.
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Any duration of physiotherapy treatment (although trials of less than one day of treatment were excluded).
Types of interventions
Physiotherapy interventions aim to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. Physiotherapy encompasses a wide range of techniques, so we were inclusive in our definition of physiotherapy intervention (including those not directly delivered by a physiotherapist) with trials of general physiotherapy, exercise, treadmill training, cueing, dance and martial arts being included.
Types of outcome measures
1. Gait outcomes such as:
a. two‐ or six‐minute walk test (m), measures the number of metres a person can walk in two or six minutes thereby providing a measurement of walking endurance (Kersten 2004);
b. walking speed:
i. 10‐ or 20‐metre walk test (s), measures the time in seconds that a person takes to walk 10 or 20 metres thereby providing a measurement of gait speed (Kersten 2004),
ii. velocity (m/s), measures the rate of change of position, recorded in metres per second (Trew 2005);
c. cadence (steps/min), measures the number of steps taken in a given period of time, which is then converted into the number of steps taken per minute (Trew 2005);
d. stride length (m), measures the average distance (in metres) between two successive placements of the same foot (Whittle 1996);
e. step length (m), measures the average distance (in metres) between successive foot to floor contact with the opposite feet (Trew 2005);
f. Freezing of Gait Questionnaire, a validated questionnaire for the assessment of freezing of gait. The questionnaire consists of six items and scores range from 0 to 24, with higher scores corresponding to more severe freezing of gait (Giladi 2000).
2. Functional mobility and balance outcomes such as:
a. timed up and go (s), measures the time taken in seconds for a person to get up from a chair, walk a certain distance (usually three metres), turn around and walk back to the chair and sit down (Podsiadlo 1991);
b. Functional Reach Test (cm), “the maximal distance one can reach forward beyond arm’s length, while maintaining a fixed base of support in the standing position” (Duncan 1990);
c. Berg Balance Scale, a validated questionnaire designed to measure functional standing balance of the older adult. The measure consists of 14 items and score ranges from 0 to 56; with 0 to 20 = high fall risk; 21 to 40 = medium fall risk; and 41 to 56 = low fall risk (Berg 1992; Qutubuddin 2005);
d. Activity Specific Balance Confidence. a 16‐item self‐report questionnaire that asks individuals to rate their confidence that they will maintain their balance in the course of daily activities. Each item is rated from 0% (no confidence) to 100% (complete confidence) (Powell 1995; Talley 2008).
3. Data on falls such as:
a. number of patients falling, e.g. falls diary;
b. Falls Efficacy Scale, a 10‐item patient‐reported questionnaire that measures how confident a person is at carrying out various ADL. Items are rated from 1 to 10, with higher scores correlating with lower levels of confidence, and a total score of 70 or more indicating that a person has a fear of falling (Tinetti 1990);
c. Falls Efficacy Scale International, a 16‐item questionnaire that includes the 10 original items of the standard Falls Efficacy Scale as well as six items regarding higher functioning and social activities. Each item is rated on a scale of 1 to 4, with 1 being ‘not concerned at all’ and 4 being ‘very concerned’ (maximum score out of 64) (Yardley 2005).
4. Clinician‐rated impairment and disability measures such as:
a. Hoehn and Yahr, a scale used to describe how symptoms of Parkinson's disease progress. Scale ranges from 0 to 5, with higher levels indicating greater disability (Hoehn 1967);
b. Unified Parkinson's Disease Rating Scale (UPDRS), designed to assess motor impairment and disability in Parkinson’s disease. Higher scores correspond to greater disability (Fahn 1987):
i. total, score ranges from 0 to 176,
ii. mental, score ranges from 0 to 16,
iii. ADL, score ranges from 0 to 52,
iv. motor, score ranges from 0 to 108;
c. Webster Rating Scale, an assessment of severity of disease and clinical impairment against 10 items using a scale of 0 = normal to 3 = maximum impairment (bradykinesia, rigidity, posture, upper extremity swing, gait, tremor at rest, facies, seborrhoea, speech, and self care). Scores ranges from 0 to 30, with higher scores indicating greater disease severity and disability (Webster 1968);
d. Columbia University Rating Scale, an assessment of motor impairment and ADL against 13 items, using a five‐point scale for each to give a total score between 0 = normal to 65 = maximum disability (Yahr 1969).
5. Patient‐rated quality of life such as:
a. Parkinson's Disease Questionnaire‐39 (PDQ‐39), a PD specific health‐related quality of life questionnaire containing 39 items divided into eight domains. Scores range from 0 to 100 with higher scores corresponding to poorer quality of life (Jenkinson 1997; Peto 1995);
b. PDQUALIF, a PD specific health‐related quality of life questionnaire containing 32 items in seven dimensions and one item of global health‐related quality of life. The total score ranges from 0 to 128 with higher scores indicating poorer quality of life (Welsh 2003);
c. PDQL, a PD specific health‐related quality of life questionnaire containing 37 items grouped into four subscales. Item scores range from 1 to 5. The PDQL‐Summary Index ranges from 37 to 185, with higher scores reflecting better quality of life (Deboer 1996);
d. Short Form‐36 (SF‐36) or 12 (SF‐12), a generic short form health survey consisting of 36 or 12 questions. The SF‐36 consists of eight scaled scores assessing vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning and mental health. Scores range from 0 to 100 with higher scores corresponding to better quality of life (Ware 1992).
6. Adverse events e.g. fractures, pain.
7. Compliance e.g. participant adherence, treatment fidelity.
8. Economic analysis.
Search methods for identification of studies
We undertook a systematic search of the literature up to the end of January 2012 for publications or abstracts describing relevant trials. This included searching the following.
1. General biomedical and science electronic databases (without date limiters) including the Cochrane Movement Disorders Specialised Register, The Cochrane Library, MEDLINE (1966 to 2012), EMBASE (1974 to 2012), CINAHL (1982 to 2012), ISI‐SCI (1981 to 2012); the rehabilitation databases AMED (1985 to 2012), REHABDATA (1995 to 2012), REHADAT (1990 to 2012), PEDro (1929 to 2012), GEROLIT (1979 to 2012); the English language databases of foreign language research and third world publications LILACS (1982 to 2012), MedCarib (17th Century to 2012) and IMEMR (1984 to 2012).
2. The Cochrane Central Register of Controlled Trials (CENTRAL), the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, RePORT, National Institute on Disability and Rehabilitation Research (NIDRR) and National Research Register (NRR).
3. Handsearching of general (Lancet, BMJ, JAMA) and specific journals (Movement Disorders,Neurology,Archives of Physical Medicine and Rehabilitation,Clinical Rehabilitation,Physiotherapy, Physical Therapy) from 2001 to the end of January 2012.
4. The reference lists of retrieved papers and review articles.
5. Abstract books and conference proceedings. This included The XIII International Congress on Parkinson's disease (1999), The International Congress of Parkinson's Disease and Movement Disorders (1990, 1992, 1994, 1996, 1998, 2000, 2002, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012), World Congress on Parkinson's Disease and Related Disorders (2009) and The American Academy of Neurology 51st annual meeting (1999).
6. Grey literature databases (including theses): Conference Proceedings Citation Index (1982 to 2012), DISSABS (1999 to 2012), Conference Papers Index (1982 to 2012), Index to Theses (1970 to 2012), Electronic Theses Online Service (EThOS) (16th Century to 2012) and ProQuest dissertations and theses databases (1861 to 2012).
The search strategies are listed in full in Appendix 1.
Data collection and analysis
Selection of studies
From the search results, two review authors (CLT, CPH, SP or LS) independently screened the abstracts of potentially relevant studies, with the full paper being obtained if the abstract did not provide sufficient information to determine eligibility for inclusion in the review. Disagreement was resolved by referral to a third review author (RS, CM or NI). Authors of potentially eligible studies were contacted for further information if details of their trial were unclear.
Data extraction and management
Two review authors (CLT, CPH, SP or CM) independently assessed the eligible papers or abstracts for trial details and outcome data. These were validated by discussion with any discrepancies resolved by consensus. Trial details were recorded on a standard trial description form and included: trial name, trial group, authors, randomised comparison, treatment schedule (including duration, number of sessions, type of intervention), other therapy, eligibility criteria, method of randomisation, allocation concealment, blinding, accrual period, number of participants randomised, number of dropouts, duration of follow‐up, outcomes reported, use of intention‐to‐treat analysis and publication date(s). The outcome data extracted included data on gait, functional mobility and balance, falls, clinician‐rated disability scale and patient‐rated quality of life, adverse events, compliance or withdrawals and health economics where available.
Authors of any eligible unpublished studies were contacted to ask if further details and the data for their trial could be provided.
Assessment of risk of bias in included studies
Two review authors (CLT, CPH, SP or CM) assessed the methodological quality of the full papers by recording the eligibility criteria (for example specified inclusion (and exclusion) criteria ‐ low risk), method of randomisation (for example used computer random number generator ‐ low risk) and blinding (for example blinding of assessors ‐ low risk), concealment of allocation (for example use of central randomisation service ‐ low risk), similarity of participants in treatment groups at baseline (no difference in baseline characteristics between treatment groups as stated in trial publication ‐ low risk), co‐intervention(s) constant (for example drug therapy stable ‐ low risk), comparable treatment arms (for example similar treatment duration and frequency ‐ low risk), whether an intention‐to‐treat analysis was performed (intention‐to‐treat analysis and withdrawals < 10% ‐ low risk, withdrawals > 10% ‐ unclear risk, per protocol analysis ‐ all unclear risk) and the number of participants lost to follow‐up and missing values (withdrawals below 10% ‐ low risk) (see the risk of bias tables under 'Characteristics of included studies').
Data synthesis
Treatment arms of the included studies were classified and divided according to the types of interventions administered:
1. general physiotherapy;
2. exercise;
3. treadmill training;
4. cueing;
5. dance;
6. martial arts.
Disparate study designs in the included trials resulted in a lack of overlap in the collated physiotherapy methods and outcome measures such that data could not be combined in a meaningful way.
Results
Description of studies
A total of 78 randomised trials of physiotherapy intervention in PD patients were identified; 29 studies were excluded (see Characteristics of excluded studies). The reasons for excluding these trials were: not randomised or not properly randomised (n = 12), cross‐over study with data for the different phases not adequately separated (n = 4), treatment given in trial not usually used by physiotherapists (such as whole body vibration technique) (n = 4), no outcome measures relevant to our review (n = 2), multidisciplinary therapy rehabilitation trial (n = 2), trial duration under one day (n = 1), insufficient information available for inclusion in review (n = 1), unsuitable comparator arm (n = 1), study was confounded (n = 1) and comparison of physiotherapy delivery rather than technique (n = 1). There were also six ongoing trials for which data were not yet available (see Characteristics of ongoing studies). Therefore, there were 43 trials available for inclusion in the review, compared to seven in the 2001 review (Figure 1).
PRISMA flow diagram.
The number of participants randomised into each of the 43 trials ranged from eight to 210 participants, with 1673 participants randomised in total (giving an average trial size of 39 participants) (see Characteristics of included studies). The assessment period ranged from two weeks to 24 months. The mean age of the participants in the trials was 67 years, 62% were male, the mean Hoehn and Yahr stage was 2.4, and they had had PD for approximately seven years.
There were 14 three‐arm trials. Eight trials compared two different experimental physiotherapy interventions with placebo or no intervention (Almeida 2012; Fisher 2008; Li 2012; Mak 2008; McGinley 2012; Shankar 2009; Talakkad 2011; Thaut 1996). The placebo or no intervention arms of these trials were not included in any analysis for this review (see Tomlinson 2012). Six trials compared three different physiotherapy techniques (Chaiwanichsiri 2011; Ebersbach 2010; Juncos 2006; Reuter 2011; Schenkman 2012a; Toole 2005). There was also one four‐arm trial comparing two types of dance (waltz or foxtrot and tango) and martial arts with no intervention (Hackney 2009).
Risk of bias in included studies
See the Characteristics of included studies risk of bias in included studies tables, risk of bias graph (Figure 2) and risk of bias summary (Figure 3).
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Trial design
A total of 40 trials had a parallel design and three had a cross‐over design (Burini 2006; Miyai 2000; Shiba 1999). Most trials looked at the short‐term effect of therapy by assessing the participants at baseline and immediately or shortly after the physiotherapy intervention period (which ranged from two weeks to 24 months). Of the parallel design trials 21 reported additional data at assessment points after the treatment period had finished; this may have been at only two weeks or up to 12 months after the end of the treatment period.
Sample size
Only 13 studies (30%) (Braun 2011; Hackney 2007; Hackney 2009; Hackney 2010; Hirsch 1996; Li 2012; McGinley 2012; Morris 2009; Picelli 2012; Reuter 2011; Schenkman 2012a; Smania 2010; Yang 2010) reported a sample size calculation in the trial report, which was achieved by seven studies.
Eligibility criteria
The eligibility criteria for the trials were broad and varied considerably across the trials. The level of detail provided on the eligibility criteria was also variable, with some studies providing a detailed description of the entry criteria and others just stating 'patients with Parkinson’s disease'. Only four trials (Pelosin 2010; Reuter 2011; Schenkman 2012a; Yang 2010) stated that a diagnosis of PD by the United Kingdom Brain Bank Criteria (Gibb 1988) was required. It is vital that eligibility criteria are well‐defined so that the trial participant population can be determined.
Randomisation method and concealment of allocation
A total of 24 trials (56%) described the randomisation method used, of which only eight trials used low risk methods (for example computer random number generators). No details of the randomisation method used were provided for the remaining 19 trials. Further, only 20 trials (47%) either stated or gave adequate information that allowed the assessment of whether an adequate concealment of treatment allocation procedure had been used. Four trials were considered to be low risk by virtue of having used a central independent randomisation service, with the other 16 considered high risk (that is concealment of treatment allocation was potentially compromised as sealed envelopes, picking a card or picking from a hat were used).
Blinding of assessors
It would be impossible to blind participants and therapists to randomised treatment allocation in trials of physiotherapy. Therefore, such trials are open label by nature, and they are consequently liable to the possibility of both performance and attrition bias. However, blinding of assessors could be employed to try and reduce the possibility of bias; 23 (53%) of the 43 studies used blinded assessors, seven used unblinded assessors so were classed as high risk, and in the other 13 studies this information was not provided (classed as unclear risk).
Co‐interventions
Information on co‐interventions was provided in 24 trials (56%), with participants continuing with their standard PD medication. In 20 trials the drug therapy was kept stable (low risk) throughout the duration of the trial, whereas five trials allowed variation (unclear risk). The remaining trials did not describe drug therapy (unclear risk).
Similarity of treatment groups at baseline
A description of the baseline characteristics of the trial participants is important to determine whether the trial results are generalisable and to compare characteristics of the two arms to ensure that the randomisation methods were successful. Six trials (Diehl 2011; Joudoux 2011; Khallaf 2011; Shankar 2009; Shen 2011; Talakkad 2011) did not provide any information on the baseline characteristics of the participants entered into the trial; 31 (of the 37) trials that reported baseline data gave this information split by treatment group; 25 trials reported sufficient data that showed participants to be similar at baseline. In six trials the baseline characteristics of the withdrawn participants were not given (Hackney 2009; Mak 2008; Miyai 2002; Picelli 2012; Smania 2010; Yang 2010). Along with the six trials that did not supply baseline data, this meant that 274 (16%) of the 1693 randomised participants were not characterised.
Data analysis
Ten trials stated intention to treat as the primary method of analysis, although it was not always clear if participants who withdrew from the trial were included in the analysis. The number of participant withdrawals was classed as low risk (≤ 10% of trial participants withdrew) in five of the 10 trials. Four trials used per protocol as the method of analysis (unclear risk). In the other 29 trials the method of analysis was not described (unclear risk), of these trials seven were considered high risk in terms of the proportion of participants that withdrew (that is > 10%), and in 13 trials the number of participant withdrawals (if any) was not described (unclear risk).
Available trial information and data
A total of 13 trials were reported in abstract form; further information was requested from the authors (two were not contactable: Khallaf 2011; Shiba 1999) with four (Juncos 2006; Poliakoff 2009; Robichaud 2012; Shankar 2009) providing additional information and seven (Diehl 2011; Hass 2006; Joudoux 2011; Loureiro 2010; Shen 2011; Sigurgeirsson 2009; Talakkad 2011) being unsuccessful. A total of 30 trials were reported as full publications; further information was requested from authors for 26 trials with 13 providing additional information.
Effects of interventions
See 'Summary of results' table for included trials (Table 1).
| Study Group | Location | Interventions | Withdrawals at post‐test (with reasons) | Outcomes | Summary of results at post‐test | ||||||
| Arm 1 | Arm 2 | Arm 3 | Arm 4 | Arm 1 | Arm 2 | Arm 3 | Arm 4 | ||||
| Waterloo, Canada | Visual cueing on the ground (n=14; 30 minutes, 3 times per week, 6 weeks) | Visual cueing on the treadmill (n=14; 30 minutes, 3 times per week, 6 weeks) | Control (n=14) | 0 | 0 | 0 | Primary: Step length Secondary: UPDRS III, timed up and go, gait speed, cadence, double support time, step time, step‐to‐step variability, step time variability, 30 second chair stand | There was no difference between treatment arms | |||
| Netherlands | Physiotherapy with mental practice (n=25; 1 hour (or 2 x 30 minutes) weekly, 6 weeks) | Physiotherapy with relaxation (n=25; 1 hour (or 2 x 30 minutes) weekly, 6 weeks) | 3 (n=2; hospitalised with relapse, n=1; too confronting) | 4 (n=3; hospitalised with relapse, n=1 died) | Visual analogue scale, timed up and go, 10 m walk test | There was no difference between treatment arms | |||||
| Ancona, Italy | Aerobic training (n=13; 45 minutes, 3 times per week, 7 weeks) | Qigong group (n=13; 45 minutes, 3 times per week, 7 weeks) | 2 (n=1; poor compliance, n=1; back pain after 3rd session) | 2 (n=1; poor compliance, n=1; fall‐related fracture) | Primary: UPDRS III, UPDRS II, Brown's disability scale (BDS), 6 minute walk test, Borg scale for breathlessness, Beck depression inventory (BDI), PDQ‐39. Secondary: Spirometry test, Maximum cardiopulmonary exercise test | There was no difference between treatment arms for primary outcomes | |||||
| Bangkok, Thailand | Treadmill with music cue (n=10; 30 minutes, 3 times per week, 4 weeks) | Treadmill (n=10; 30 minutes, 3 times per week, 4 weeks) | Home walking (n=10; 30 minutes, 3 times per week, 4 weeks) | 0 | 0 | 0 | Timed up and go, Walking speed, Step length, Cadence, Stride length, 6‐minute walk test, 6 metre walk time, Single leg stance, UPDRS I, II, III | There was no difference between treatment arms | |||
| Brasil, South America | Physiotherapy and cardiovascular exercise with visual cues (n=8; total 20 sessions) | Conventional physiotherapy (n=8; total 20 sessions) | 0 | 0 | UPDRS, Functional independence measurement scale, Berg balance scale, H&Y scale | Physiotherapy and cardiovascular exercise with visual cues significantly improved functional independent measure, step length, velocity (gait speed) and cadence compared to conventional physiotherapy | |||||
| Indiana, USA | Group Box training (n=unknown, total n=20) | Traditional group exercise (n=unknown, total n=20) | unknown | unknown | Berg balance scale, Activities specific balance confidence scale, Functional reach test, Parkinson's disease quality of life scale | There was no difference between treatment arms | |||||
| Beelitz‐Heilsãtten, Germany | LSVT BIG training (n=20; 1 hour, 4 times per week, 4 weeks) | Nordic Walking (n=20; 1 hour, twice a week, 8 weeks) | Home exercise (n=20; 1 session) | 0 | 1 (n=1; withdrawal of consent) | 1 (n=1; withdrawn due to psychosis) | Primary: UPDRS III. Secondary: PDQ‐39, Timed up and go, time to walk 10 m | Significant improvement of UPDRS, timed up and go and timed 10m walking in LSVT BIG group compared to Nordic walking and home exercise. There was no difference between treatment arms for PDQ‐39 | |||
| Los Angeles, California | Treadmill group (n=10; 1 hour, 3 times per week, 8 weeks) | Physiotherapy group (n=10; 1 hour, 3 times per week, 8 weeks) | Control group (n=10; 1 hour, total of 6 sessions over 8 weeks) | 0 | 0 | 0 | UPDRS (Total, I, II and III subscores), Hoehn and Yahr, Functional assessments, Walking tests: average gait velocity, step length, stride length, cadence, double limb support time, ankle, knee, hip rotation. Sit‐to‐stand test, Transcranial magnetic stimulation (subset) | There was no difference between treatment arms | |||
| Montescano, Italy | Treadmill with auditory and visual cues (n=20; 20 minutes daily, 4 weeks) | Auditory and visual cues (n=20; 20 minutes daily, 4 weeks) | 0 | 0 | UPDRS III, Gait speed, Freezing of gait questionnaire, Stride length, 6 minute walking test | The treadmill with auditory and visual cues had significant improvement in gait speed, freezing of gait questionnaire, stride length and 6 minute walking test when compared to the auditory and visual cues group. There were no differences between treatment arms for UPDRS III | |||||
| St. Louis, Missouri, USA | Tango (n=9; 1 hour, 20 sessions within 13 weeks) | Exercise (n=10; 1 hour, 20 sessions within 13 weeks) | 0 | 0 | UPDRS III, Berg balance scale, Freezing of gait, Timed up and go, Velocity of walking and dual‐task walking | There was no difference between treatment arms | |||||
| St. Louis, Missouri, USA | Tango group (n=19; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Waltz/foxtrot group (n=19; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Tai Chi group (n=17; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Control group (n=20; 13 weeks) | 5 (n= 1; personal problems, n=1; knee pain, n=2; transportation problems, n=1; change in medication) | 2 (n=1; injury at home, n=1; infrequent attendance (unknown)) | 4 (n=2; transportation problems, n=1; hospitalisation (unrelated), n=1; insufficiently intense exercise) | 3 (n=1; hospitalisation (unrelated), n=1; ankle injury, n=1; death in family) | PDQ‐39, UPDRS III, Berg balance scale, Tandem stance test, Timed up and go test, One leg stance test 6 minute walk test, Gait | PDQ‐39 significantly improved in the tango arm compared to the waltz/foxtrot and Tai Chi arms. Timed up and go test was significantly improved in the tango arm compared to the waltz/foxtrot and Tai Chi arms. There was no difference between treatment arms in UPDRS III | |
| St. Louis, Missouri, USA | Partnered tango (n=19; 1 hour, twice weekly, 10 weeks) | Non‐partnered tango (n=20; 1 hour, twice weekly, 10 weeks) | 7 (n=1; progressive decline in mental status, n=2; excessive travelling distance, n=1; felt classes were too fatiguing, n=3; unable to return for follow‐up measures) | 5 (n=1; expressed lack of interest, n=1; new job interfered with class, n=1; unrelated medical problems, n=1; work commitments, n=1; unable to return for follow‐up measures) | Tandem stance, one leg stance, Timed up and go, 6 minute walk test, Gait velocity, Cadence, Stride length, Swing percentage, Double support percentage | There was no difference between treatment arms | |||||
| Florida, USA | Tai Chi (n=unknown, total n=23; 1 hour, twice weekly, 16 weeks) | Qi‐gong (n=unknown, total n=23; 1 hour, twice weekly, 16 weeks) | Unknown | Unknown | Gait initiation, Gait velocity, Stride length, Stance, Double limb support, Step duration | There was no difference between treatment arms | |||||
| North Carolina, USA | Combined balance and resistance training (n=6; 45 minutes, 3 times per week, 10 weeks) | Balance training group (n=9; 30 minutes, 3 times per week, 10 weeks) | 0 | 0 | Balance, Muscle strength (subset group): knee extensors, knee flexors, ankle plantar flexors. Latency to fall, % of trials resulting in falls | Combined balance and resistance training improved balance scores significantly more than the balance training group. There were no differences between treatment arms for the falls outcomes | |||||
| Crétil, France | Asymmetric motor training program (n=unknown, total n=50; 1 hour, 3 times per week, 8 weeks) | Broad program (n=unknown, total n=50; 1 hour, 3 times per week, 8 weeks) | Unknown | Unknown | UPDRS III, GMT score, Rapid alternating movements, Handwriting and spiralography, PDQ‐39, Dpression (GDS‐15), Video recording of 8 activities of daily living and biomechanical evaluations | Abatract describing methodology. No result data | |||||
| Georgia, USA | Aerobic exercise (n=unknown, total n=56; 6 months) | Tai Chi (n=unknown, total n=56; 6 months) | Qi‐gong (n=unknown, total n=56; 6 months) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | UPDRS total, UPDRS motor, UPDRS ADL, PDQ‐39, Clinical global impression, Walking speed, Falls | UPDRS ADL scores improved significantly more with Qi‐gong than aerobic exercise. There was no difference between treatment arms for PDQ‐39 and UPDRS total and motor subscores. There was insufficient information on clinical global impression, walking speed and falls | |||
| Saudi Arabia | Physiotherapy and treadmill (n=15) | Physiotherapy (n=15) | Unknown | Unknown | UPDRS II & III, Hamilton rating scale of depression, Walking speed, Walking distance | Both treatment arms showed significant improvement in walking distance, speed and ADL. A significant improvement in depression only observed in physiotherapy and treadmill group. Unclear if there were any differences between treatment arms | |||||
| Oregon, USA | Tai Chi (n=65; 1 hour, twice weekly, 24 weeks) | Resistance training (n=65; 1 hour, twice weekly, 24 weeks) | Control, stretching group (n=65; 1 hour, twice weekly, 24 weeks) | 9 (n=4; health problem, n=3; noncommittal/time conflict, n=2; relocating) | 6 (n=4; health problem, n=1; noncommittal/time conflict, n=1; relocating) | 4 (n=3; health problem, n=1; noncommittal/time conflict) | Primary: Two indicators of postural stability: maximum excursion and directional control. Secondary: Stride length, Walking velocity, Strength of bilateral knee extensors and flexors, Functional reach test, Timed up and go, UPDRS III, Number of falls | The Tai Chi group performed significantly better than those in the resistance training and stretching groups on the primary outcomes. The Tai Chi group had significantly better performance/scores in many outcomes compared to the stretching group. The Tai Chi group out performed the resistance training group on the stride length and functional reach | |||
| Católica do Paraná, Brazil | Conventional physical therapy (n=6, sessions, twice weekly, total 12 sessions) | Complementary activities (n=6, sessions, twice weekly, total 12 sessions) | Unknown | Unknown | Timed up and go, Anterior functional reach | There was no difference between treatment arms | |||||
| Hong Kong, China | Audio‐visual cued task‐specific training (n=21; 20 minutes, 3 times per week, 4 weeks) | Conventional exercise (n=21; 45 minutes, twice weekly, 4 weeks) | Control (n=18; 4 weeks) | 2 (n=1; change of medication, n=1; heel pain) | 2 (n=1; fall with fracture, n=1; went overseas) | 4 (n=2; declined to come back, n=2; went overseas) | Peak horizontal velocity, Peak vertical velocity, Movement time,3 D Kinematics data of sit‐to‐stand | The audio‐visual cued task‐specific training group increased both peak horizontal and vertical velocities and reduced time taken to complete sit‐to‐stand. These improvements were greater than those of the conventional exercise group and control | |||
| Carlton, Australia | Movement strategy training (n=69; 2 hours + 2 hours home practice program, once a week, 8 weeks) | Progressive strength training (n=70; 2 hours + 2 hours home practice program, once a week, 8 weeks) | Life skills control (n=71; 2 hours + 2 hours home practice program, once a week, 8 weeks) | 2 (n=1; unable or unwilling to attend, n=1; death) | 1 (n=1; health reasons) | 12 (n=2; unable or unwilling to attend, n=2; poor health, n=1; preference for exercise group, n=1; death, n=2; health reasons, n=1; unspecified, n=1; group was "depressing", n=2, not exercising or receiving falls education) | Primary: Falls: no. of fallers per group, no. of multiple fallers per group, falls rate over 12 months in each group. Secondary: Number of injurious falls, Walking speed, 6 minute walk test, Timed up and go, UPDRS II and III, PDQ‐39, EuroQol‐5D | Time to first fall during the intervention phase did not differ across groups. Full trial results not yet published | |||
| Osaka, Japan | Body weight supported treadmill training (n=5; 45 minutes, three times per week, 4 weeks) | Physical therapy (n=5; 45 minutes, three times per week, 4 weeks) | 0 | 0 | UPDRS, UPDRS subscales (mental, ADL, motor and complications), Overground ambulation endurance, Gait speed, No. steps taken for 10 metre walk | Cross‐over trial, combined data presented. Body weight‐supported treadmill training showed greater improvement in UPDRS total, ambulation speed and number of steps than physical therapy arm. Additional data supplied by author allowed data to be separated and there was no difference between arms | |||||
| Osaka, Japan | Body weight supported treadmill training (n=11; 45 minutes, three times per week, 4 weeks) | Physical therapy (n=9; 45 minutes, three times per week, 4 weeks) | 1 (n=1, medication changed) | 3 (n=3, medication changed) | Primary: UPDRS, Gait speed, No. steps taken for 10 metre walk. Secondary: UPDRS subscales (mental, ADL, motor and complications) | Body weight‐supported treadmill training had significantly greater improvement than the physical therapy group in gait speed at 1 month; and in the number of steps at 1, 3 and 4 months | |||||
| Melbourne, Australia | Movement strategy training (n=14; 45 minutes, max 16 sessions over 2 weeks) | Musculoskeletal exercise (n=14; 45 minutes, max 16 sessions over 2 weeks) | 0 | 2 (n=2; lost to follow up, no details) | Primary: UPDRS Motor and ADL (combined). Secondary: 10 m walk test, Timed up and go, 2 min walk test, Balance‐shoulder tug, PDQ‐39 | The movement strategy training group had a significant improvement in balance compared to the musculoskeletal arm. There were no other differences between treatment arms | |||||
| Minneapolis, Minnesota, USA | United Parkinson Foundation exercise program (n=7; 1 hour, three times per week, 12 weeks) | Upper body karate training program (n=7; 1 hour, three times per week, 12 weeks) | 0 | 0 | Forearm pronation/supination rate, Pursuit score walk index, Degree of activated rigidity, Degree of arm tremor, Activated rigidity, Grip strength, 9‐hole peg test, Minnesota placing and turning test, Arm swings test, Rapid alternating arm movement test, Button board, Putting shirt on and off, Putting shoes and socks on and off, Getting up from chair, Long latency stretch response | Study did not compare differences between treatment arms | |||||
| Genova, Italy | Action plus physical therapy group (n=9; 1 hour, three times per week, 4 weeks) | Landscape plus physical therapy group (n=9; 1 hour, three times per week, 4 weeks) | 1 (n=1; found to have past history of neurological conditions other than PD or implantation for deep brain stimulation) | 1 (n=1; found to have past history of neurological conditions other than PD or implantation for deep brain stimulation) | FOG Questionnaire and FOG diary, Timed up and go, 10 metre walking test, Tinetti scale part I and II, Berg balance scale, PDQ‐39 | At post‐test there was no difference between treatment arms | |||||
| Verona, Italy | Robot assisted gait‐training group (n=21; 45 minutes, three times per week, 4 weeks) | Physiotherapy group (n=20; 45 minutes, three times per week, 4 weeks) | 3 (n=3; lack of cooperation) | 2 (n=2; lack of cooperation) | Primary: 10 m walk test, 6 min walk test. Secondary: Spatiotemporal gait parameters including stride length, Parkinson's fatigue scale, UPDRS Total | Robot assisted gait‐training significantly improved 10 m walk test, 6 min walk test, Parkinson's fatigue scale, UPDRS Total compared to the physiotherapy group | |||||
| Manchester, UK | 20 week gym group (n=16; 1 hour, twice a week, 20 weeks) | 10 week gym group (n=16; 1 hour, twice a week, 10 weeks) | 4 (n=1; randomised but did not start intervention, n=3; did not complete or insufficient sessions) | 6 (n=1; randomised but did not start intervention, n=5; did not complete or insufficient sessions) | Simple, choice and serial reaction time, Videotaped motor performance, PDQ‐39, UPDRS III, Illness perceptions (BIPQ), Questionnaire assessing experiences of programme | No significant differences between arms, except for the learning sequence RT outcome | |||||
| Giessen, Germany | Nordic walking group (n=30; 70 minutes, three times per week, 6 months) | Walking group (n=30; 70 minutes, three times per week, 6 months) | Flexibility and relaxation group (n=30; 70 minutes, three times per week, 6 months) | 0 | 0 | 0 | Max walking speed on treadmill, 12 m and 24 m walking test, Stride length, Gait variability, UPDRS, PDQ‐39, Physical activity in everyday life, Adverse effects | Main reported differences were that the Nordic walking group was superior to the walking and flexibility and relaxation programme in improving postural stability, stride length, gait pattern, and gait variability | |||
| Cleveland, Ohio, USA | Forced exercise group (n=5; 1 hour, 3 times per week, 8 weeks) | Voluntary exercise group (n=5; 1 hour, 3 times per week, 8 weeks) | 0 | 0 | UPDRS part III Manual functional dexterity, Bimanual dexterity, Centre of pressure (CoP) | UPDRS motor scores showed a significantly greater improvement in the forced exercise arm compared to the voluntary exercise arm. Only forced exercise resulted in significant improvements in bimanual dexterity | |||||
| Chicago, Illinois, USA | Progressive resistance exercise (n=unknown (total n=48 at 6 month time point); 1 hour, twice per week, 24 months) | Fitness counts (n=unknown (total n=48 at 6 month time point); 1 hour, twice per week, 24 months) | Unknown | Unknown | UPDRS motor, Timed up and go, Berg balance scale, Modified physical performance test | There was no difference between treatment arms | |||||
| Denver, Colorado, USA | Flexibilty/balance/function exercise group (n=39; 1 hour, 3 times per week for the first 4 months then tapered for 1 month to once monthly sessions out to 16 months) | Aerobic exercise group (n=41; 1 hour, 3 times per week for the first 4 months then tapered for 1 month to once monthly sessions out to 16 months) | Home exercise group (n=41; once monthly supervised sessions) | 3 at 4 months (n=1; health problems, n=2; personal issues) | 7 at 4 months (n=1; not happy with the program, n=2; missed appointment, n=2; health problems, n=1; moved, n=1; deceased) | 6 at 4 months (n=3; not happy with the program, n=1; did not return calls, n=1 unable to commit the time, n=1; missed appointment) | Primary: Overall physical function, Balance ‐ functional reach, Walking economy ‐ VO2 Secondary: UPDRS ADL, UPDRS Motor, PDQ‐39 | Overall physical function: improvement at 4 months was greater in the Flexibilty/balance/function exercise group than the aerobic and home exercise group. Functional reach was not different between groups. Walking economy: aerobic exercise improved compared to Flexibilty/balance/function exercise group. The only secondary outcome that showed significant differences was UPDRS ADL: Flexibilty/balance/function exercise group performed better than home exercise group at 4 months | |||
| Calgary, Canada | Treadmill with cueing group (n=10; 30 minutes, twice a week, 8 weeks) | Treadmill without cueing (n=9; 30 minutes, twice a week, 8 weeks) | Cueing only group (n=10; 30 minutes, twice a week, 8 weeks) | 0 | 0 | 0 | Gait and Balance Scale, UPDRS III, PDQ‐39 | Limited data. There was no difference between treatment arms | |||
| Hong Kong, China | Balance group (n=23; treatment delivered over 12 weeks) | Strength training (n=22; treatment delivered over 12 weeks) | 0 | 0 | Limit of stability, Walking speed, One leg stance time, Activities‐specific balance confidence scale, UPDRS III | Limited data. The balance group improved significantly more than the strength group in movement velocity and one leg stance | |||||
| Kanagawa, Japan | Visual stimulation (n=unknown, total n=8; treated for an unknown period of time) | Auditory stimulation (n=unknown, total n=8; treated for an unknown period of time) | 0 | 0 | Stride length | Stride length was significantly greater after visual stimulation than after auditory stimulation gait training | |||||
| Reykjalundur, Iceland | Walking with visual cues (n=unknown, total n=26; 30 minutes, 4 sessions per week, 4 weeks) | Walking without cues (n=unknown, total n=26; 30 minutes, 4 sessions per week, 4 weeks) | Unknown | Unknown | Timed up and go, PDQ‐39 | Limited data. There was no difference between treatment arms for Timed up and go | |||||
| Verona, Italy | Balance training (n=33; 50 minutes, 3 times per week, 7 weeks) | General physical exercise (n=31; 50 minutes, 3 times per week, 7 weeks) | 5 (n=2; uncooperativeness, n=3; medical complications) | 4 (n=2; uncooperativeness, n=2; medical complications) | Primary: Berg balance scale, Activities‐specific balance confidence, Postural transfer test, Self destabilization of the centre of foot pressure test, Falls diary. Secondary: UPDRS Total, Modified Hoehn and Yahr, Geriatric depression scale | There was a significant difference in favour of the balance training arm in the Berg Balance Scale and the self destabilization of the centre of foot pressure test when compared to the general physical exercise group | |||||
| Bangalore, India | Conventional gait training (n=unknown, total n=60; 8 hours over 4 weeks) | Partial weight supported treadmill training: 20% unweighting (n=unknown, total n=60; 8 hours over 4 weeks) | Control: No specific intervention (n=unknown, total n=60) | Unknown | Unknown | Unknown | Dynamic posturography, UPDRS (total and motor subscore), Beat‐to‐beat finger blood pressure | Limited data. Partial weight supported (‐20%) treadmill training had a significantly greater improvement in UPDRS motor score compared to conventional gait training | |||
| Colorado, USA | Novel rhythmic auditory stimulation group (n=15; 30 minutes per day, total 10.5 hours over 3 weeks) | Standard self paced training group (n=11; 30 minutes per day, total 10.5 hours over 3 weeks) | No treatment group (n=11) | 0 | 0 | 0 | Stride velocity, Stride cadence, Stride length, EMG analysis on leg muscles | Rhythmic auditory stimulation group improved significantly for flat and incline velocity compared to the self paced training. The rhythmic auditory stimulation group's improvements in stride length were only significantly better than the no treatment group and changes in cadence were only significantly higher than the self paced training group | |||
| Florida, USA | Standard treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Unweighted treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Weighted treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Unknown | Unknown | Unknown | Balance from dynamic posturography, Berg balance scale, UPDRS, Biomechanical assessment of strength and range of motion, Gait | There was no difference between treatment arms for function and stability in gait and dynamic balance | |||
| A Coruña, Spain | Water based exercise group (n=6; 45 minutes, twice weekly, 4 weeks) | Land based exercise group (n=6; 45 minutes, twice weekly, 4 weeks) | 1 (n=1; influenza ‐ did not receive intervention) | 0 | Functional reach test, Berg balance scale, Gait ‐turn time, velocity, cadence, step amplitude, Timed up and go, UPDRS | The water based exercise group significantly improved Berg Balance Scale and UPDRS compared to the land based exercise group. There was no difference between treatment arms for the remaining outcomes | |||||
| New York, USA | Verbal instruction with augmented feedback group (n=6; 90 minutes, 2 times per week, 2 weeks) | Verbal instruction only group (n=6; 90 minutes, 2 times per week, 2 weeks) | 0 | 0 | Stride length, Cadence, Gait velocity, Shoulder excursion | There was no difference between treatment arms | |||||
| Taipei, Taiwan | Downhill walking group (n=16; 30 minutes, 3 times per week, 4 weeks) | Physiotherapy group (n=17; 30 minutes, 3 times per week, 4 weeks) | 1 (n=1; low motivation) | 2 (n=1; conflicting work schedule, n=1; transport problem) | Speed, Candence, Stride length, Thoriacic kyphosis, Muscle strength | Downhill walking significantly improved gait speed, stride length and muscle strength of knee extensors compared to physiotherapy | |||||
The physiotherapy interventions were placed into one of the six categories (general physiotherapy, exercise, treadmill training, cueing, dance and martial arts) according to the type of treatment administered. However, the content and delivery of the interventions within each category were diverse and varied substantially. Further, a wide variety of validated and customised outcome measures were used to assess the effectiveness of the physiotherapy interventions. Consequently, it was inappropriate to combine the results of studies or perform any statistical analysis.
Nevertheless, results of the most regularly used outcome measures could be examined on a trial by trial basis. The most frequently reported physiotherapy outcome measures were gait speed and timed up and go. The motor subscales of the UPDRS and PDQ‐39 were the most commonly reported clinician‐rated disability and patient‐rated quality of life outcome measures respectively. Falls data were also considered to be an important outcome in PD. Even in the case of these more widely reported outcome measures, quantitative meta‐analysis could not be performed due to the wide variety of interventions employed by the included studies such that no two studies with comparable interventions assessed the same outcome measure.
Gait speed (m/s)
Gait speed was measured in 19 studies with data available from 15 studies; data were inadequately or not reported for four trials (Juncos 2006; Khallaf 2011; McGinley 2012; Shen 2011). Nine (Almeida 2012; Chaiwanichsiri 2011; Fisher 2008; Hackney 2007; Hass 2006; Li 2012; Miyai 2000; Vivas 2011; Werner 2010) of the 15 studies reported no difference between the two intervention arms. In five studies (Dias 2005 (mean difference between arms 0.34 m/s); Frazzitta 2009 (mean difference between arms 0.1 m/s); Miyai 2002 (mean difference between arms 0.16 m/s); Thaut 1996 (mean difference between arms 0.093 m/s); Yang 2010 (mean difference between arms 0.15 m/s)) the gait speed was significantly increased in the novel experimental arm compared to the comparator arm. The remaining study (Hackney 2009) was a three‐arm trial. Hackney (Hackney 2009) recorded significantly greater gait speed in the tango arm compared to the waltz/foxtrot arm (mean difference between arms 0.06m/s), but not the Tai Chi arm.
Timed up and go (s)
The timed up and go test was reported in 15 studies with data available from 14 studies; data were inadequately or not reported for one study (McGinley 2012). There was no difference between the two intervention arms for 12 studies (Almeida 2012; Braun 2011; Chaiwanichsiri 2011; Hackney 2007; Hackney 2010; Li 2012; Loureiro 2010; Morris 2009; Pelosin 2010; Robichaud 2012; Sigurgeirsson 2009; Vivas 2011). In the Ebersbach (Ebersbach 2010) study, the time taken to complete the timed up and go test was significantly improved (that is reduced) with the Lee Silverman voice treatment (LSVT) BIG arm compared to the Nordic walking and home exercise arms. In the Hackney (Hackney 2009) study, the timed up and go test was significantly improved in the tango arm compared to the waltz or foxtrot and Tai Chi arms.
Falls
Outcome measures that report data on falls are important and pertinent in PD studies. However, only five trials reported data on falls (11%) (Hirsch 1996; Juncos 2006; Li 2012; McGinley 2012; Smania 2010).
Hirsch 1996 reported the effect of training on mean latency to fall (average number of seconds participants swayed before stepping or falling, touching the surrounding panels with hands, or needing assistance from the technician to keep from sitting in the harness) and the proportion of falls (number of trials resulting in falls). There were no significant differences between the combined balance and resistance arm and balance only arm for either outcome.
Juncos 2006 was published in abstract form. There was insufficient information on the falls data collected to allow a description of the manner in which falls were analysed or to give any indication of the result.
Li 2012 monitored falls using daily ‘falls calendars’ that were maintained by study participants. There were no differences between the Tai Chi and resistance training arms.
McGinley 2012 measured the number of fallers, the number of multiple fallers and falls rate. The number of falls during the intervention phase (eight weeks) was significantly lower in the progressive strength training arm compared to the movement strategy training arm (n = 10 versus n = 24; P = 0.006), with the frequency of falls varying markedly. However, the time to first fall did not differ significantly between groups (P = 0.4).
Smania 2010 reported the number of falls by means of a falls diary. A diary of the number of falls, their circumstances, and the consequences for the patient’s health were kept for one month prior to each evaluation session. There was no significant difference between the balance training experimental arm and the general physical exercises arm.
Clinician‐rated disability
UPDRS motor subscale
The motor subscale of the UPDRS was reported in 23 studies with data and information available from 17; data were inadequately or not reported for six studies (Joudoux 2011; Khallaf 2011; Reuter 2011; Shankar 2009; Shen 2011; Toole 2005). There was no difference between the two intervention arms for 14 studies (Almeida 2012; Burini 2006; Fisher 2008; Frazzitta 2009; Hackney 2007; Hackney 2009; Juncos 2006; Li 2012; McGinley 2012; Miyai 2000; Miyai 2002; Poliakoff 2009; Robichaud 2012; Schenkman 2012a). In the Ebersbach 2010 study, the UPDRS motor score was significantly improved in the LSVT BIG arm compared to the Nordic walking and home exercise arms. In the Ridgel 2009 study, UPDRS motor scores showed a significantly greater improvement in the forced exercise arm compared to the voluntary exercise arm. In the Talakkad 2011 study, partial weight supported (‐20%) treadmill training had a significantly greater improvement in UPDRS motor score compared to conventional gait training (no data in publication).
Patient‐rated quality of life
PDQ‐39 (Summary Index)
A total of 13 studies described using data from the PDQ‐39 but the data were only available from eight studies; data were inadequately or not reported in five studies (Joudoux 2011; McGinley 2012; Reuter 2011; Shankar 2009; Sigurgeirsson 2009). Seven studies (Burini 2006; Ebersbach 2010; Juncos 2006; Morris 2009; Pelosin 2010; Poliakoff 2009; Schenkman 2012a) reported no difference between the intervention arms. Only the Hackney 2009 trial reported a significant difference, with quality of life scores significantly improved in the tango arm compared to the waltz or foxtrot and Tai Chi arms.
Adverse events
Nine trials recorded adverse event data (Chaiwanichsiri 2011; Fisher 2008; Li 2012; McGinley 2012; Picelli 2012; Poliakoff 2009; Reuter 2011; Schenkman 2012a; Yang 2010). Minor adverse events such as muscle soreness, falls and dizziness were reported, with none of these trials reporting events significant enough to cause concern over the safety of the intervention.
Compliance
Only 18 of the 43 trials discussed participant compliance, with 13 (Burini 2006; Ebersbach 2010; Hackney 2007; Hackney 2009; Hirsch 1996; Li 2012; McGinley 2012; Miyai 2000; Miyai 2002; Poliakoff 2009; Reuter 2011; Thaut 1996; Toole 2005) quantifying it in some form; however this was difficult to analyse.
Health economics
Only one trial (McGinley 2012) intended to look at health economics. Watts 2008 (See McGinley 2012) published a protocol for economic analysis alongside the McGinley trial. They proposed to evaluate cost‐effectiveness using a three‐way comparison of the cost per fall averted and the cost per quality adjusted life year saved across two physical therapy interventions and a control group.
Discussion
Summary of main results
This review updates the previous Cochrane review published in 2001 (Deane 2001b) comparing the effectiveness of one approach of physiotherapy intervention versus a second approach of physiotherapy intervention for the treatment of PD. The review now includes 43 randomised trials and 1693 participants (compared with seven trials and 142 participants in the 2001 review). Many recent systematic reviews have focused on specific areas of physiotherapy such as exercise, cueing and treadmill training (Allen 2011; Crizzle 2006; Goodwin 2008; Lim 2005; Mehrholz 2010; Nieuwboer 2008). Physiotherapy for PD encompasses a wide range of methods and techniques ranging from standard UK National Health Service (NHS) physiotherapy to exercise regimens and martial arts (Tomlinson 2012). Therefore, it is important that all approaches of physiotherapy intervention are included. Physiotherapy interventions were placed into six categories according to the type of treatment administered. However, the content and delivery of the interventions within each category varied substantially. In view of the disparate study designs, variety of interventions, and the array of outcome measures used the results of individual studies could not be combined using quantitative meta‐analysis methods.
Comparison of different physiotherapy interventions
A recent Cochrane review provided evidence on the short‐term benefit of physiotherapy in the treatment of PD (Tomlinson 2012). However, it did not identify whether any specific type of physiotherapy intervention provides greater benefit. This review aimed to assess this by comparing the effectiveness of one approach of physiotherapy intervention with a second approach of physiotherapy intervention. The various physiotherapy interventions used in the trials included in this review were categorised according to the type of treatment administered to aid comparisons (general physiotherapy, exercise, treadmill training, cueing, dance, martial arts). However, despite categorisation, the techniques employed within each category were diverse. Therefore, it was not possible or appropriate to combine the results by meta‐analysis as any such analysis would be difficult to interpret. It is also difficult to summarise such large amounts of heterogeneous data using a qualitative approach. Consequently, we conclude that there is no robust trial evidence to support any one approach of physiotherapy over another in the treatment of PD.
The content and delivery of the interventions used in the trials included within this review were diverse in nature. Although attempts were made to compare trials that were 'like for like' through the creation of different categories, the interventions delivered varied substantially within these categories. In the future it may be useful to further subcategorise by the primary aim of the trial. For example, categories for the primary aim might be to improve gait or improve a specific problem such as gait freezing or balance, or improve overall PD performance or function. The variation in the therapy delivered is unsurprising. Physiotherapy is an autonomous profession. Physiotherapists use different sets of skills and work within their own scope of practice (Chartered Society of Physiotherapy), and so this variation in the interventions delivered within clinical trials may reflect the diversity of clinical practice. Over the past decade, steps have been taken to try and provide best practice consensus in the form of the Dutch KNGF guidelines for physical therapy in patients with Parkinson’s disease (Keus 2004). However, this publication provides a guidance framework rather than a 'recipe' for treatment. It is therefore important that physiotherapy interventions are compared against each other within rigorous trial designs to determine which are the most effective. This will provide therapists with a menu of treatment strategies that are known to be effective, from which they can devise individualised interventions. However, given the complexity of physiotherapy interventions, it is important that such trials follow the Medical Research Council guidelines for developing and evaluating complex interventions (MRC 2008), which will help standardise interventions. In addition, many of the trials included in this review had interventions that were intensive and for long durations, which may not be feasible in main stream care. Therefore, future trials should be designed such that the interventions are transferable and cost‐effective in main stream care.
Outcome measures
There was a large variety of outcome measures utilised in the different studies included in this review. The majority of the outcomes were standard physiotherapy and PD outcomes. Gait speed, timed up and go, UPDRS motor score and quality of life measured using the PDQ‐39 were the most frequently reported outcome measures within their respective categories. PD is a multidimensional disease and several important outcomes were either poorly or not reported; this includes data on the number of the falls, depression and anxiety and adverse events. Further, many of the outcomes measured were not relevant to the PD patient or carer. There is a need for the use of functional gait outcomes in future trials which look at the impact on the patient during everyday living rather than in a laboratory environment. Further, only one trial intended to look at a health economics analysis of physiotherapy intervention, therefore little is known about the cost‐effectiveness and economic value of this therapy. Future trials should include these outcomes.
Gait speed
Six trials (Dias 2005; Frazzitta 2009; Hackney 2009; Miyai 2002; Thaut 1996; Yang 2010) reported significant differences between the treatment arms for gait speed. The observed differences between treatment arms ranged from 0.06 to 0.34 m/s. In all these trials, with the exception of Hackney 2009, the intervention arm that used cueing or treadmill training methods, or both, was the better treatment arm. The Hackney trial (Hackney 2009) examined dance with the tango arm outperforming the waltz or foxtrot arm. The possible relevance and benefit of these significant differences to patients with PD must be put into context in terms of what is considered a minimally clinically important change (MCIC). Data on what is considered an MCIC are lacking for PD patients, but some data have been reported in stroke patients. In one study, it was reported that an increase in speed of just 0.03 and 0.13 m/s could translate into a change from a limited household to an unlimited household walker, and from an unlimited household walker to a most‐limited community walker, respectively (Perry 1995). Therefore, these differences in gait speed between arms are consistent with the findings reported by Perry (Perry 1995).
Timed up and go
The MCIC in PD patients is thought to be 11 seconds (Steffen 2008). The differences seen between treatment arms in the Ebersbach (Ebersbach 2010) and Hackney trials (Hackney 2009) were much smaller than this (the mean difference between arms ranged from 1.1 to 2 seconds).
UPDRS motor subscale
Three trials reported a significant benefit of one treatment arm in improving UPDRS motor over the other arms. The UPDRS motor score in the LSVT BIG arm in the Ebersbach (Ebersbach 2010) trial improved by 5.05 points, which was significantly different from the two other arms in which the score increased (that is got worse) by 0.53 and 1.68 points in the Nordic walking and home exercise arms, respectively. Ridgel (Ridgel 2009) reported a significant difference in UPDRS motor score between the forced exercise arm (‐16.6 points) and the voluntary exercise arm (3.6 points). Additionally, Talakkad (Talakkad 2011) reported a significantly greater improvement of the UPDRS motor score in the partial weight supported (‐20%) treadmill training compared to conventional gait training, although there were no data in the abstract publication. The MCIC for the UPDRS motor score has been reported in two studies. One analysed data from two independent randomised controlled trials and concluded that the MCIC was five points for the motor score (Schrag 2006). The second study performed a cross‐sectional analysis on 653 PD participants and reported a MCIC of 2.3 to 2.7 points for the motor score (Shulman 2010). Considering the recommendations of both Schrag (Schrag 2006) and Shulman et al (Shulman 2010) the improvements seen in the Ebersbach (Ebersbach 2010) and Ridgel (Ridgel 2009) trials may reflect a MCIC.
Patient‐rated quality of life
A study performed by Peto et al (Peto 2001) to determine the MCIC for the PDQ‐39 Parkinson’s questionnaire reported that a difference of 1.6 on the summary index was a meaningful change. Only the Hackney 2009 trial reported a significant difference, with quality of life scores significantly improved by 7.10 points in the tango arm, which was significantly different from the waltz or foxtrot arm that improved by 0.68 points and the Tai Chi arm which had an increased score of 1.55 points (that is got worse). This improvement in quality of life that was seen in the tango arm is therefore meaningful to patients.
Quality of the evidence
There has been an improvement in the trial methodological quality and reporting since the last Cochrane review (Deane 2001b). The use of more robust randomisation methods, blinding and intention‐to‐treat analyses has increased since the previous review, although it was still inadequate. Of the 43 trials, only 24 trials provided information on the randomisation method (of which eight were considered low risk) and only four used a central independent randomisation procedure to ensure concealment of treatment allocation; 23 trials used blinded assessors and only 10 stated that they used intention‐to‐treat analysis methods. The lack of information in many trial reports may not necessarily indicate lack of implementation within the trial, but without this information provided in the trial publications the level of bias within the individual trials is difficult to assess. The need for further improvement in the methodological quality of trials in physiotherapy for PD was noted recently (Kwakkel 2007; Tomlinson 2012). Future trials must be methodologically sound, large, randomised, and controlled with reporting following CONSORT guidelines (Boutron 2008a; Boutron 2008b).
The trials included in the review were relatively small, with the majority assessing the effect of one approach of physiotherapy intervention versus a second approach of physiotherapy intervention over a short period of time, with limited follow‐up. The overall size of trials has increased (with an average of 39 participants per trial in this review compared to 20 in the previous review), but the number of small and underpowered trials remains a problem. Small trials may be subject to ‘random error’ (Doll 1980) and consequently may give rise to false negative or positive results. Further, it must be noted that the mean age of onset of PD in the participants in the trials was 60 years. This is relatively young as the average age of onset in the PD MED trial is 67 to 69 years (Patel 2010), therefore the results of the trials may not be relevant to the general PD population, in particular older PD patients.
It should also be noted that only 18 of the 43 trials discussed participant compliance. This is surprising as compliance can be an important determinant of the outcomes measured and the acceptability of the interventions being assessed in the trials. Therefore, it would be beneficial if the level of compliance is measured in future trials.
Another limitation is that the follow‐up period in the trials included in this review was relatively short. Outcome measures were assessed in all trials at baseline and immediately or shortly after the intervention had ceased (one or two weeks, with one trial (Ebersbach 2010) assessing at 12 weeks post‐intervention). PD is a long‐term neurodegenerative disease, so it is important that the long‐term effect of treatment is assessed. Only half of the 43 trials followed‐up participants and reported further data during the post‐treatment period (but this could have been only two weeks or up to 12 months post‐treatment). The previous review’s recommendations were for participants to be followed‐up for at least six months. Only two trials did this, reporting follow‐up data at 12 months (McGinley 2012) and at both 6 and 12 months (Werner 2010) post‐treatment. Long‐term data will provide valuable information about the duration of any improvement following therapy.
Reporting biases
Many trials used multiple outcome measures, and in the majority of trials the primary outcome measure was not explicitly stated. Therefore, it was difficult to assess and identify if studies were free of selective outcome reporting.
In order to minimise the risk of publication bias, a comprehensive search was performed of multiple databases, including searching of unpublished and ongoing studies, without any language restrictions. Also, where necessary, authors were contacted to request additional information. However, as with any systematic review, publication bias should still be taken into consideration.
In summary, large, well‐designed randomised trials with improved specific treatment strategies and a follow‐up of at least 12 months that assess the impact of treatment on all aspects of a patient's PD, alongside a health economics assessment, are needed.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
| Study Group | Location | Interventions | Withdrawals at post‐test (with reasons) | Outcomes | Summary of results at post‐test | ||||||
| Arm 1 | Arm 2 | Arm 3 | Arm 4 | Arm 1 | Arm 2 | Arm 3 | Arm 4 | ||||
| Waterloo, Canada | Visual cueing on the ground (n=14; 30 minutes, 3 times per week, 6 weeks) | Visual cueing on the treadmill (n=14; 30 minutes, 3 times per week, 6 weeks) | Control (n=14) | 0 | 0 | 0 | Primary: Step length Secondary: UPDRS III, timed up and go, gait speed, cadence, double support time, step time, step‐to‐step variability, step time variability, 30 second chair stand | There was no difference between treatment arms | |||
| Netherlands | Physiotherapy with mental practice (n=25; 1 hour (or 2 x 30 minutes) weekly, 6 weeks) | Physiotherapy with relaxation (n=25; 1 hour (or 2 x 30 minutes) weekly, 6 weeks) | 3 (n=2; hospitalised with relapse, n=1; too confronting) | 4 (n=3; hospitalised with relapse, n=1 died) | Visual analogue scale, timed up and go, 10 m walk test | There was no difference between treatment arms | |||||
| Ancona, Italy | Aerobic training (n=13; 45 minutes, 3 times per week, 7 weeks) | Qigong group (n=13; 45 minutes, 3 times per week, 7 weeks) | 2 (n=1; poor compliance, n=1; back pain after 3rd session) | 2 (n=1; poor compliance, n=1; fall‐related fracture) | Primary: UPDRS III, UPDRS II, Brown's disability scale (BDS), 6 minute walk test, Borg scale for breathlessness, Beck depression inventory (BDI), PDQ‐39. Secondary: Spirometry test, Maximum cardiopulmonary exercise test | There was no difference between treatment arms for primary outcomes | |||||
| Bangkok, Thailand | Treadmill with music cue (n=10; 30 minutes, 3 times per week, 4 weeks) | Treadmill (n=10; 30 minutes, 3 times per week, 4 weeks) | Home walking (n=10; 30 minutes, 3 times per week, 4 weeks) | 0 | 0 | 0 | Timed up and go, Walking speed, Step length, Cadence, Stride length, 6‐minute walk test, 6 metre walk time, Single leg stance, UPDRS I, II, III | There was no difference between treatment arms | |||
| Brasil, South America | Physiotherapy and cardiovascular exercise with visual cues (n=8; total 20 sessions) | Conventional physiotherapy (n=8; total 20 sessions) | 0 | 0 | UPDRS, Functional independence measurement scale, Berg balance scale, H&Y scale | Physiotherapy and cardiovascular exercise with visual cues significantly improved functional independent measure, step length, velocity (gait speed) and cadence compared to conventional physiotherapy | |||||
| Indiana, USA | Group Box training (n=unknown, total n=20) | Traditional group exercise (n=unknown, total n=20) | unknown | unknown | Berg balance scale, Activities specific balance confidence scale, Functional reach test, Parkinson's disease quality of life scale | There was no difference between treatment arms | |||||
| Beelitz‐Heilsãtten, Germany | LSVT BIG training (n=20; 1 hour, 4 times per week, 4 weeks) | Nordic Walking (n=20; 1 hour, twice a week, 8 weeks) | Home exercise (n=20; 1 session) | 0 | 1 (n=1; withdrawal of consent) | 1 (n=1; withdrawn due to psychosis) | Primary: UPDRS III. Secondary: PDQ‐39, Timed up and go, time to walk 10 m | Significant improvement of UPDRS, timed up and go and timed 10m walking in LSVT BIG group compared to Nordic walking and home exercise. There was no difference between treatment arms for PDQ‐39 | |||
| Los Angeles, California | Treadmill group (n=10; 1 hour, 3 times per week, 8 weeks) | Physiotherapy group (n=10; 1 hour, 3 times per week, 8 weeks) | Control group (n=10; 1 hour, total of 6 sessions over 8 weeks) | 0 | 0 | 0 | UPDRS (Total, I, II and III subscores), Hoehn and Yahr, Functional assessments, Walking tests: average gait velocity, step length, stride length, cadence, double limb support time, ankle, knee, hip rotation. Sit‐to‐stand test, Transcranial magnetic stimulation (subset) | There was no difference between treatment arms | |||
| Montescano, Italy | Treadmill with auditory and visual cues (n=20; 20 minutes daily, 4 weeks) | Auditory and visual cues (n=20; 20 minutes daily, 4 weeks) | 0 | 0 | UPDRS III, Gait speed, Freezing of gait questionnaire, Stride length, 6 minute walking test | The treadmill with auditory and visual cues had significant improvement in gait speed, freezing of gait questionnaire, stride length and 6 minute walking test when compared to the auditory and visual cues group. There were no differences between treatment arms for UPDRS III | |||||
| St. Louis, Missouri, USA | Tango (n=9; 1 hour, 20 sessions within 13 weeks) | Exercise (n=10; 1 hour, 20 sessions within 13 weeks) | 0 | 0 | UPDRS III, Berg balance scale, Freezing of gait, Timed up and go, Velocity of walking and dual‐task walking | There was no difference between treatment arms | |||||
| St. Louis, Missouri, USA | Tango group (n=19; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Waltz/foxtrot group (n=19; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Tai Chi group (n=17; 1 hour, twice weekly, total 20 sessions in 13 weeks) | Control group (n=20; 13 weeks) | 5 (n= 1; personal problems, n=1; knee pain, n=2; transportation problems, n=1; change in medication) | 2 (n=1; injury at home, n=1; infrequent attendance (unknown)) | 4 (n=2; transportation problems, n=1; hospitalisation (unrelated), n=1; insufficiently intense exercise) | 3 (n=1; hospitalisation (unrelated), n=1; ankle injury, n=1; death in family) | PDQ‐39, UPDRS III, Berg balance scale, Tandem stance test, Timed up and go test, One leg stance test 6 minute walk test, Gait | PDQ‐39 significantly improved in the tango arm compared to the waltz/foxtrot and Tai Chi arms. Timed up and go test was significantly improved in the tango arm compared to the waltz/foxtrot and Tai Chi arms. There was no difference between treatment arms in UPDRS III | |
| St. Louis, Missouri, USA | Partnered tango (n=19; 1 hour, twice weekly, 10 weeks) | Non‐partnered tango (n=20; 1 hour, twice weekly, 10 weeks) | 7 (n=1; progressive decline in mental status, n=2; excessive travelling distance, n=1; felt classes were too fatiguing, n=3; unable to return for follow‐up measures) | 5 (n=1; expressed lack of interest, n=1; new job interfered with class, n=1; unrelated medical problems, n=1; work commitments, n=1; unable to return for follow‐up measures) | Tandem stance, one leg stance, Timed up and go, 6 minute walk test, Gait velocity, Cadence, Stride length, Swing percentage, Double support percentage | There was no difference between treatment arms | |||||
| Florida, USA | Tai Chi (n=unknown, total n=23; 1 hour, twice weekly, 16 weeks) | Qi‐gong (n=unknown, total n=23; 1 hour, twice weekly, 16 weeks) | Unknown | Unknown | Gait initiation, Gait velocity, Stride length, Stance, Double limb support, Step duration | There was no difference between treatment arms | |||||
| North Carolina, USA | Combined balance and resistance training (n=6; 45 minutes, 3 times per week, 10 weeks) | Balance training group (n=9; 30 minutes, 3 times per week, 10 weeks) | 0 | 0 | Balance, Muscle strength (subset group): knee extensors, knee flexors, ankle plantar flexors. Latency to fall, % of trials resulting in falls | Combined balance and resistance training improved balance scores significantly more than the balance training group. There were no differences between treatment arms for the falls outcomes | |||||
| Crétil, France | Asymmetric motor training program (n=unknown, total n=50; 1 hour, 3 times per week, 8 weeks) | Broad program (n=unknown, total n=50; 1 hour, 3 times per week, 8 weeks) | Unknown | Unknown | UPDRS III, GMT score, Rapid alternating movements, Handwriting and spiralography, PDQ‐39, Dpression (GDS‐15), Video recording of 8 activities of daily living and biomechanical evaluations | Abatract describing methodology. No result data | |||||
| Georgia, USA | Aerobic exercise (n=unknown, total n=56; 6 months) | Tai Chi (n=unknown, total n=56; 6 months) | Qi‐gong (n=unknown, total n=56; 6 months) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | Unknown (total n=16: n=2; serious adverse events, n=14; unrelated medical or logistical problems) | UPDRS total, UPDRS motor, UPDRS ADL, PDQ‐39, Clinical global impression, Walking speed, Falls | UPDRS ADL scores improved significantly more with Qi‐gong than aerobic exercise. There was no difference between treatment arms for PDQ‐39 and UPDRS total and motor subscores. There was insufficient information on clinical global impression, walking speed and falls | |||
| Saudi Arabia | Physiotherapy and treadmill (n=15) | Physiotherapy (n=15) | Unknown | Unknown | UPDRS II & III, Hamilton rating scale of depression, Walking speed, Walking distance | Both treatment arms showed significant improvement in walking distance, speed and ADL. A significant improvement in depression only observed in physiotherapy and treadmill group. Unclear if there were any differences between treatment arms | |||||
| Oregon, USA | Tai Chi (n=65; 1 hour, twice weekly, 24 weeks) | Resistance training (n=65; 1 hour, twice weekly, 24 weeks) | Control, stretching group (n=65; 1 hour, twice weekly, 24 weeks) | 9 (n=4; health problem, n=3; noncommittal/time conflict, n=2; relocating) | 6 (n=4; health problem, n=1; noncommittal/time conflict, n=1; relocating) | 4 (n=3; health problem, n=1; noncommittal/time conflict) | Primary: Two indicators of postural stability: maximum excursion and directional control. Secondary: Stride length, Walking velocity, Strength of bilateral knee extensors and flexors, Functional reach test, Timed up and go, UPDRS III, Number of falls | The Tai Chi group performed significantly better than those in the resistance training and stretching groups on the primary outcomes. The Tai Chi group had significantly better performance/scores in many outcomes compared to the stretching group. The Tai Chi group out performed the resistance training group on the stride length and functional reach | |||
| Católica do Paraná, Brazil | Conventional physical therapy (n=6, sessions, twice weekly, total 12 sessions) | Complementary activities (n=6, sessions, twice weekly, total 12 sessions) | Unknown | Unknown | Timed up and go, Anterior functional reach | There was no difference between treatment arms | |||||
| Hong Kong, China | Audio‐visual cued task‐specific training (n=21; 20 minutes, 3 times per week, 4 weeks) | Conventional exercise (n=21; 45 minutes, twice weekly, 4 weeks) | Control (n=18; 4 weeks) | 2 (n=1; change of medication, n=1; heel pain) | 2 (n=1; fall with fracture, n=1; went overseas) | 4 (n=2; declined to come back, n=2; went overseas) | Peak horizontal velocity, Peak vertical velocity, Movement time,3 D Kinematics data of sit‐to‐stand | The audio‐visual cued task‐specific training group increased both peak horizontal and vertical velocities and reduced time taken to complete sit‐to‐stand. These improvements were greater than those of the conventional exercise group and control | |||
| Carlton, Australia | Movement strategy training (n=69; 2 hours + 2 hours home practice program, once a week, 8 weeks) | Progressive strength training (n=70; 2 hours + 2 hours home practice program, once a week, 8 weeks) | Life skills control (n=71; 2 hours + 2 hours home practice program, once a week, 8 weeks) | 2 (n=1; unable or unwilling to attend, n=1; death) | 1 (n=1; health reasons) | 12 (n=2; unable or unwilling to attend, n=2; poor health, n=1; preference for exercise group, n=1; death, n=2; health reasons, n=1; unspecified, n=1; group was "depressing", n=2, not exercising or receiving falls education) | Primary: Falls: no. of fallers per group, no. of multiple fallers per group, falls rate over 12 months in each group. Secondary: Number of injurious falls, Walking speed, 6 minute walk test, Timed up and go, UPDRS II and III, PDQ‐39, EuroQol‐5D | Time to first fall during the intervention phase did not differ across groups. Full trial results not yet published | |||
| Osaka, Japan | Body weight supported treadmill training (n=5; 45 minutes, three times per week, 4 weeks) | Physical therapy (n=5; 45 minutes, three times per week, 4 weeks) | 0 | 0 | UPDRS, UPDRS subscales (mental, ADL, motor and complications), Overground ambulation endurance, Gait speed, No. steps taken for 10 metre walk | Cross‐over trial, combined data presented. Body weight‐supported treadmill training showed greater improvement in UPDRS total, ambulation speed and number of steps than physical therapy arm. Additional data supplied by author allowed data to be separated and there was no difference between arms | |||||
| Osaka, Japan | Body weight supported treadmill training (n=11; 45 minutes, three times per week, 4 weeks) | Physical therapy (n=9; 45 minutes, three times per week, 4 weeks) | 1 (n=1, medication changed) | 3 (n=3, medication changed) | Primary: UPDRS, Gait speed, No. steps taken for 10 metre walk. Secondary: UPDRS subscales (mental, ADL, motor and complications) | Body weight‐supported treadmill training had significantly greater improvement than the physical therapy group in gait speed at 1 month; and in the number of steps at 1, 3 and 4 months | |||||
| Melbourne, Australia | Movement strategy training (n=14; 45 minutes, max 16 sessions over 2 weeks) | Musculoskeletal exercise (n=14; 45 minutes, max 16 sessions over 2 weeks) | 0 | 2 (n=2; lost to follow up, no details) | Primary: UPDRS Motor and ADL (combined). Secondary: 10 m walk test, Timed up and go, 2 min walk test, Balance‐shoulder tug, PDQ‐39 | The movement strategy training group had a significant improvement in balance compared to the musculoskeletal arm. There were no other differences between treatment arms | |||||
| Minneapolis, Minnesota, USA | United Parkinson Foundation exercise program (n=7; 1 hour, three times per week, 12 weeks) | Upper body karate training program (n=7; 1 hour, three times per week, 12 weeks) | 0 | 0 | Forearm pronation/supination rate, Pursuit score walk index, Degree of activated rigidity, Degree of arm tremor, Activated rigidity, Grip strength, 9‐hole peg test, Minnesota placing and turning test, Arm swings test, Rapid alternating arm movement test, Button board, Putting shirt on and off, Putting shoes and socks on and off, Getting up from chair, Long latency stretch response | Study did not compare differences between treatment arms | |||||
| Genova, Italy | Action plus physical therapy group (n=9; 1 hour, three times per week, 4 weeks) | Landscape plus physical therapy group (n=9; 1 hour, three times per week, 4 weeks) | 1 (n=1; found to have past history of neurological conditions other than PD or implantation for deep brain stimulation) | 1 (n=1; found to have past history of neurological conditions other than PD or implantation for deep brain stimulation) | FOG Questionnaire and FOG diary, Timed up and go, 10 metre walking test, Tinetti scale part I and II, Berg balance scale, PDQ‐39 | At post‐test there was no difference between treatment arms | |||||
| Verona, Italy | Robot assisted gait‐training group (n=21; 45 minutes, three times per week, 4 weeks) | Physiotherapy group (n=20; 45 minutes, three times per week, 4 weeks) | 3 (n=3; lack of cooperation) | 2 (n=2; lack of cooperation) | Primary: 10 m walk test, 6 min walk test. Secondary: Spatiotemporal gait parameters including stride length, Parkinson's fatigue scale, UPDRS Total | Robot assisted gait‐training significantly improved 10 m walk test, 6 min walk test, Parkinson's fatigue scale, UPDRS Total compared to the physiotherapy group | |||||
| Manchester, UK | 20 week gym group (n=16; 1 hour, twice a week, 20 weeks) | 10 week gym group (n=16; 1 hour, twice a week, 10 weeks) | 4 (n=1; randomised but did not start intervention, n=3; did not complete or insufficient sessions) | 6 (n=1; randomised but did not start intervention, n=5; did not complete or insufficient sessions) | Simple, choice and serial reaction time, Videotaped motor performance, PDQ‐39, UPDRS III, Illness perceptions (BIPQ), Questionnaire assessing experiences of programme | No significant differences between arms, except for the learning sequence RT outcome | |||||
| Giessen, Germany | Nordic walking group (n=30; 70 minutes, three times per week, 6 months) | Walking group (n=30; 70 minutes, three times per week, 6 months) | Flexibility and relaxation group (n=30; 70 minutes, three times per week, 6 months) | 0 | 0 | 0 | Max walking speed on treadmill, 12 m and 24 m walking test, Stride length, Gait variability, UPDRS, PDQ‐39, Physical activity in everyday life, Adverse effects | Main reported differences were that the Nordic walking group was superior to the walking and flexibility and relaxation programme in improving postural stability, stride length, gait pattern, and gait variability | |||
| Cleveland, Ohio, USA | Forced exercise group (n=5; 1 hour, 3 times per week, 8 weeks) | Voluntary exercise group (n=5; 1 hour, 3 times per week, 8 weeks) | 0 | 0 | UPDRS part III Manual functional dexterity, Bimanual dexterity, Centre of pressure (CoP) | UPDRS motor scores showed a significantly greater improvement in the forced exercise arm compared to the voluntary exercise arm. Only forced exercise resulted in significant improvements in bimanual dexterity | |||||
| Chicago, Illinois, USA | Progressive resistance exercise (n=unknown (total n=48 at 6 month time point); 1 hour, twice per week, 24 months) | Fitness counts (n=unknown (total n=48 at 6 month time point); 1 hour, twice per week, 24 months) | Unknown | Unknown | UPDRS motor, Timed up and go, Berg balance scale, Modified physical performance test | There was no difference between treatment arms | |||||
| Denver, Colorado, USA | Flexibilty/balance/function exercise group (n=39; 1 hour, 3 times per week for the first 4 months then tapered for 1 month to once monthly sessions out to 16 months) | Aerobic exercise group (n=41; 1 hour, 3 times per week for the first 4 months then tapered for 1 month to once monthly sessions out to 16 months) | Home exercise group (n=41; once monthly supervised sessions) | 3 at 4 months (n=1; health problems, n=2; personal issues) | 7 at 4 months (n=1; not happy with the program, n=2; missed appointment, n=2; health problems, n=1; moved, n=1; deceased) | 6 at 4 months (n=3; not happy with the program, n=1; did not return calls, n=1 unable to commit the time, n=1; missed appointment) | Primary: Overall physical function, Balance ‐ functional reach, Walking economy ‐ VO2 Secondary: UPDRS ADL, UPDRS Motor, PDQ‐39 | Overall physical function: improvement at 4 months was greater in the Flexibilty/balance/function exercise group than the aerobic and home exercise group. Functional reach was not different between groups. Walking economy: aerobic exercise improved compared to Flexibilty/balance/function exercise group. The only secondary outcome that showed significant differences was UPDRS ADL: Flexibilty/balance/function exercise group performed better than home exercise group at 4 months | |||
| Calgary, Canada | Treadmill with cueing group (n=10; 30 minutes, twice a week, 8 weeks) | Treadmill without cueing (n=9; 30 minutes, twice a week, 8 weeks) | Cueing only group (n=10; 30 minutes, twice a week, 8 weeks) | 0 | 0 | 0 | Gait and Balance Scale, UPDRS III, PDQ‐39 | Limited data. There was no difference between treatment arms | |||
| Hong Kong, China | Balance group (n=23; treatment delivered over 12 weeks) | Strength training (n=22; treatment delivered over 12 weeks) | 0 | 0 | Limit of stability, Walking speed, One leg stance time, Activities‐specific balance confidence scale, UPDRS III | Limited data. The balance group improved significantly more than the strength group in movement velocity and one leg stance | |||||
| Kanagawa, Japan | Visual stimulation (n=unknown, total n=8; treated for an unknown period of time) | Auditory stimulation (n=unknown, total n=8; treated for an unknown period of time) | 0 | 0 | Stride length | Stride length was significantly greater after visual stimulation than after auditory stimulation gait training | |||||
| Reykjalundur, Iceland | Walking with visual cues (n=unknown, total n=26; 30 minutes, 4 sessions per week, 4 weeks) | Walking without cues (n=unknown, total n=26; 30 minutes, 4 sessions per week, 4 weeks) | Unknown | Unknown | Timed up and go, PDQ‐39 | Limited data. There was no difference between treatment arms for Timed up and go | |||||
| Verona, Italy | Balance training (n=33; 50 minutes, 3 times per week, 7 weeks) | General physical exercise (n=31; 50 minutes, 3 times per week, 7 weeks) | 5 (n=2; uncooperativeness, n=3; medical complications) | 4 (n=2; uncooperativeness, n=2; medical complications) | Primary: Berg balance scale, Activities‐specific balance confidence, Postural transfer test, Self destabilization of the centre of foot pressure test, Falls diary. Secondary: UPDRS Total, Modified Hoehn and Yahr, Geriatric depression scale | There was a significant difference in favour of the balance training arm in the Berg Balance Scale and the self destabilization of the centre of foot pressure test when compared to the general physical exercise group | |||||
| Bangalore, India | Conventional gait training (n=unknown, total n=60; 8 hours over 4 weeks) | Partial weight supported treadmill training: 20% unweighting (n=unknown, total n=60; 8 hours over 4 weeks) | Control: No specific intervention (n=unknown, total n=60) | Unknown | Unknown | Unknown | Dynamic posturography, UPDRS (total and motor subscore), Beat‐to‐beat finger blood pressure | Limited data. Partial weight supported (‐20%) treadmill training had a significantly greater improvement in UPDRS motor score compared to conventional gait training | |||
| Colorado, USA | Novel rhythmic auditory stimulation group (n=15; 30 minutes per day, total 10.5 hours over 3 weeks) | Standard self paced training group (n=11; 30 minutes per day, total 10.5 hours over 3 weeks) | No treatment group (n=11) | 0 | 0 | 0 | Stride velocity, Stride cadence, Stride length, EMG analysis on leg muscles | Rhythmic auditory stimulation group improved significantly for flat and incline velocity compared to the self paced training. The rhythmic auditory stimulation group's improvements in stride length were only significantly better than the no treatment group and changes in cadence were only significantly higher than the self paced training group | |||
| Florida, USA | Standard treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Unweighted treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Weighted treadmill group (n=unknown, total n=23; 20 minutes, 3 times per week, 6 weeks) | Unknown | Unknown | Unknown | Balance from dynamic posturography, Berg balance scale, UPDRS, Biomechanical assessment of strength and range of motion, Gait | There was no difference between treatment arms for function and stability in gait and dynamic balance | |||
| A Coruña, Spain | Water based exercise group (n=6; 45 minutes, twice weekly, 4 weeks) | Land based exercise group (n=6; 45 minutes, twice weekly, 4 weeks) | 1 (n=1; influenza ‐ did not receive intervention) | 0 | Functional reach test, Berg balance scale, Gait ‐turn time, velocity, cadence, step amplitude, Timed up and go, UPDRS | The water based exercise group significantly improved Berg Balance Scale and UPDRS compared to the land based exercise group. There was no difference between treatment arms for the remaining outcomes | |||||
| New York, USA | Verbal instruction with augmented feedback group (n=6; 90 minutes, 2 times per week, 2 weeks) | Verbal instruction only group (n=6; 90 minutes, 2 times per week, 2 weeks) | 0 | 0 | Stride length, Cadence, Gait velocity, Shoulder excursion | There was no difference between treatment arms | |||||
| Taipei, Taiwan | Downhill walking group (n=16; 30 minutes, 3 times per week, 4 weeks) | Physiotherapy group (n=17; 30 minutes, 3 times per week, 4 weeks) | 1 (n=1; low motivation) | 2 (n=1; conflicting work schedule, n=1; transport problem) | Speed, Candence, Stride length, Thoriacic kyphosis, Muscle strength | Downhill walking significantly improved gait speed, stride length and muscle strength of knee extensors compared to physiotherapy | |||||
