A Manipulation of Visual Feedback during Gait Training in Parkinson's Disease

Feedback control of heart rate during robotics-assisted tilt table exercise in patients after stroke: a clinical feasibility study

BACKGROUND

Patients with neurological disorders including stroke use rehabilitation to improve cognitive abilities, to regain motor function and to reduce the risk of further complications. Robotics-assisted tilt table technology has been developed to provide early mobilisation and to automate therapy involving the lower limbs. The aim of this study was to evaluate the feasibility of employing a feedback control system for heart rate (HR) during robotics-assisted tilt table exercise in patients after a stroke.

METHODS

This feasibility study was designed as a case series with 12 patients ( n = 12 ) with no restriction on the time post-stroke or on the degree of post-stroke impairment severity. A robotics-assisted tilt table was augmented with force sensors, a work rate estimation algorithm, and a biofeedback screen that facilitated volitional control of a target work rate. Dynamic models of HR response to changes in target work rate were estimated in system identification tests; nominal models were used to calculate the parameters of feedback controllers designed to give a specified closed-loop bandwidth; and the accuracy of HR control was assessed quantitatively in feedback control tests.

RESULTS

Feedback control tests were successfully conducted in all 12 patients. Dynamic models of heart rate response to imposed work rate were estimated with a mean root-mean-square (RMS) model error of 2.16 beats per minute (bpm), while highly accurate feedback control of heart rate was achieved with a mean RMS tracking error (RMSE) of 2.00 bpm. Control accuracy, i.e. RMSE, was found to be strongly correlated with the magnitude of heart rate variability (HRV): patients with a low magnitude of HRV had low RMSE, i.e. more accurate HR control performance, and vice versa.

CONCLUSIONS

Feedback control of heart rate during robotics-assisted tilt table exercise was found to be feasible. Future work should investigate robustness aspects of the feedback control system. Modifications to the exercise modality, or alternative modalities, should be explored that allow higher levels of work rate and heart rate intensity to be achieved.

Motivational Modulation Enhances Movement Performance in Parkinson's Disease: A Systematic Review

Background

The assessment of motivation and its modulation during treatment are essential aspects of physical therapy practice. However, the modulation of motivation has been sparsely investigated in persons with Parkinson's disease (PD) and at present no studies have synthesized its effects on movement performance.

Objectives

4The purpose of this study was to systematically examine the efficacy of motivational modulation on movement performance in PD and to provide recommendations for its role in physical therapy practice.

Methods

Systematic identification of published literature was performed adhering to PRISMA guidelines, from January 2005 to March 2023. Keywords were used in the following electronic databases: PubMed, Academic Search Complete, the Cochrane Database, Google Scholar, and the Physiotherapy Evidence Database (PEDro). A level of evidence rating was completed according to the scale provided by the American Academy of Cerebral Palsy and Development Medicine. Quality assessments were performed using the Modified Downs and Black checklist.

Results

Eight studies were included in this review, all achieving level III evidence. The methodological quality of studies was varied, with most studies attaining a fair rating. Persons with PD performed upper extremity movement tasks with greater intensity when incentivized with larger rewards compared to smaller incentives. Dopamine replacement medication, Deep Brain Stimulation, and a history of depression, had mediating effects on the response to motivational modulation.

Conclusions

Our findings suggest that it is plausible to improve adherence to exercise when physical therapists modulate motivation through computerized game achievements, gamification of tasks, or other forms of reward and non-rewarding stimuli.

Restoring walking ability in older adults with arm-in-arm gait training: study protocol for the AAGaTT randomized controlled trial

CONTEXT

Falls are a significant problem among older adults. While balance and functional exercises have been shown to be effective, it remains unclear whether regular walking has specific effects on reducing the risk of falls.

RATIONALE

Older people who fall frequently have impaired gait patterns. Recent studies have suggested using interpersonal synchronization: while walking arm-in-arm, an older person synchronizes steps with a younger person to reinstate a better gait pattern. This method of gait training may reduce the risk of falls.

OBJECTIVE

The aim is to assess the efficacy of an arm-in-arm gait-training program in older people.

DESIGN

The arm-in-arm gait training trial (AAGaTT) is a single-site, open label, two-arm, randomized controlled trial.

PARTICIPANTS

We will enroll 66 dyads of older people and their younger "gait instructors". The older participants must be > 70 years old with adequate walking ability. They must have experienced a fall in the year prior to study entry.

INTERVENTION

Dyads will walk an indoor course for 30 min either side-by-side without contact (control group) or arm-in-arm while synchronizing their gait (intervention group). The gait training will be repeated three times a week for four weeks.

OUTCOMES

The main outcome will be the walking speed measured in five-minute walking trials performed at baseline and at the end of each intervention week (week 1 - week 4), and at week 7. Gait quality will be assessed using accelerometers. We will also assess perceived physical activity and health using questionnaires. Finally, we will monitor fall incidence over 18 months. We will evaluate whether outcomes are more improved in the intervention group compared to the control group. In addition, interviews will be conducted to assess the perception of the gait training.

EXPECTED RESULTS

Recent advances in the neurophysiology of motor control have shown that synchronizing gait to external cues or to a human partner can increase the efficiency of gait training. The expected benefits of arm-in-arm gait training are: reduced risk of falls, safe treatment with no adverse effects, and high adherence. This gait training program could be a low-cost intervention with positive effects on the health and well-being of seniors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05627453. Date of registration: 11.25.2022.

Effects of wearable visual cueing on gait pattern and stability in patients with Parkinson’s disease

The present study examined the effects of wearable visual cues, provided by a wearable laser device, on the gait pattern and stability in patients with Parkinson’s disease (PD). In total, 18 patients with a clinical diagnosis of idiopathic PD (Hoehn and Yahr stage II-III) and 18 healthy controls were included. The main outcome measures included spatiotemporal parameters, sagittal plane kinematic parameters of joints in lower limbs, and dynamic center of pressure (COP) parameters. Significant intra-group improvement in gait parameters was observed in PD patients. Compared with that at baseline, the gait pattern improved in PD patients under the cued condition, with longer stride length and higher toe clearance, as well as shortening of double stance phase, especially the stride length, double stance phase and toe clearance were not significantly different between cued condition and healthy control groups. In kinematics, the ankle peak dorsiflexion in swing phase and the hip range of motion (ROM) in gait cycle was significantly improved in PD patients with visual cues and close to healthy controls. Decreased anteroposterior (AP) position of COP improved gait stability in patients with PD under the cued condition. Multiple linear regression analysis showed that the AP position has a negative correlation with ankle peak dorsiflexion in swing phase. Pearson’s correlation coefficients showed that the minimum toe clearance (Mini TC) was positively correlated with the ankle peak dorsiflexion in swing phase. The immediate effect of wearable visual cues improved the gait pattern and stability in PD patients, suggesting that it may be effective when applied as an alternative technique in rehabilitation training for PD patients.

The influence of visual feedback on alleviating freezing of gait in Parkinson's disease is reduced by anxiety

BACKGROUND

Previous research has established that anxiety is associated with freezing of gait (FOG) in Parkinson's disease (PD). Although providing body-related visual feedback has been previously suggested to improve FOG, it remains unclear whether anxiety-induced FOG might be improved.

RESEARCH QUESTION

The current study aimed to evaluate whether body-related visual feedback (VF) improves FOG consistently across low and high threat conditions.

METHODS

Sixteen PD patients with FOG were instructed to walk across a plank in a virtual environment that was either located on the ground (low threat) or elevated above a deep pit (high threat). Additionally, visual feedback (VF) was either provided (+) or omitted (-) using an avatar that was synchronised in real-time with the participants movements.

RESULTS

revealed that in the low threat condition (i.e., ground), %FOG was significantly reduced when VF was provided (VF+) compared to when VF was absent (VF-). In contrast, during the elevated high threat condition, there were no differences in %FOG regardless of whether VF was provided or not.

SIGNIFICANCE

These findings confirm that although VF can aid in the reduction of FOG, anxiety may interfere with freezers' ability to use sensory feedback to improve FOG and hence, in high threat conditions, VF was unable to aid in the reduction of FOG. Future studies should direct efforts towards the treatment of anxiety to determine whether better management of anxiety may improve FOG.

Influence of radial optic flow stimulation on static postural balance in Parkinson's disease: A preliminary study

The role of optic flow in the control of balance in persons with Parkinson's disease (PD) has yet to be studied. Since basal ganglia are understood to have a role in controlling ocular fixation, we have hypothesized that persons with PD would exhibit impaired performance in fixation tasks, i.e., altered postural balance due to the possible relationships between postural disorders and visual perception. The aim of this preliminary study was to investigate how people affected by PD respond to optic flow stimuli presented with radial expanding motion, with the intention to see how the stimulation of different retinal portions may alter the static postural sway. We measured the body sway using center of pressure parameters recorded from two force platforms during the presentation of the foveal, peripheral and full field radial optic flow stimuli. Persons with PD had different visual responses in terms of fixational eye movement characteristics, with greater postural alteration in the sway area and in the medio-lateral direction than the age-matched control group. Balance impairment in the medio-lateral oscillation is often observed in persons with atypical Parkinsonism, but not in Parkinson's disease. Persons with PD are more dependent on visual feedback with respect to age-matched control subjects, and this could be due to their impaired peripheral kinesthetic feedback. Visual stimulation of standing posture would provide reliable signs in the differential diagnosis of Parkinsonism.

Brain Activity Response to Visual Cues for Gait Impairment in Parkinson's Disease: An EEG Study

Background. Gait impairments are common in Parkinson's disease (PD) and increase falls risk. Visual cues can improve gait in PD, particularly freezing of gait (FOG), but mechanisms involved in visual cue response are unknown. This study aimed to examine brain activity in response to visual cues in people with PD who do (PD+FOG) and do not report FOG (PD-FOG) and explore relationships between attention, brain activity and gait. Methods. Mobile EEG measured brain activity during gait in 20 healthy older adults and 43 PD participants (n=22 PD+FOG, n=21 PD-FOG). Participants walked for 2-minutes with and without visual cues (transverse lines to step over). We report power spectral density (PSD) in Delta (1-4 Hz), Theta (4-7 Hz), Alpha (8-12 Hz), Beta (14-24 Hz) and Gamma (30-50 Hz) bands within clusters of similarly brain localized independent component sources. Results. PSDs within the parietal and occipital lobes were altered when walking with visual cues in PD, particularly in PD+FOG. Between group, differences suggested that parietal sources in PD, particularly with PD+FOG, had larger activity compared to healthy older adults when walking. Within group, visual cues altered brain activity in PD, particularly in PD+FOG, within visual processing brain regions. In PD participants, brain activity differences with cues correlated with gait improvements, and in PD+FOG those with worse attention required more visual attentional processing (reduced alpha PSD) in the occipital lobe. Conclusions. Visual cues improve gait and influence brain activity during walking in PD, particularly in PD+FOG. Findings may allow development of more effective therapeutics.

Physical Therapy for Freezing of Gait and Gait Impairments in Parkinson Disease: A Systematic Review

INTRODUCTION

Freezing of gait (FOG) is a major cause of falls and disability in Parkinson disease (PD). As FOG only partially improves in response to dopaminergic medication, physical therapy is an important element of its management.

OBJECTIVE

To assess the evidence for the physical interventions for FOG and gait impairments and to establish recommendations for clinical practice.

LITERATURE SURVEY

This review follows the guidelines for systematic reviews: the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Systematic search in PubMed, Embase, Physiotherapy Evidence Databases, and CINAHL for randomized controlled trials of PT interventions for FOG in PD patients until April 2018.

SYNTHESIS

Twenty randomized controlled trials (RCTs) were reviewed. In 12 RCTs, PT for FOG was assessed, which was the primary outcome measure in nine of these RCTs. In eight RCTs, PT for gait impairment (not targeting specifically FOG) in PD was assessed. The following PT interventions reduce FOG with a good category A recommendation: cueing strategies (P < .05) (visual and auditory); treadmill walking (P < .05); aquatic obstacle training (P < .01); supervised slackline training (P < .05). These interventions can be combined and maintain their efficacy when being applied concurrently: though there is a lack of long-term follow-up studies. The following PT interventions show possible benefit and need further investigations: balance and coordination training; aquatic gait training; sensory (tactile) cues. The treadmill training and auditory and visual cues are effective also for other gait disturbances in PD and improve gait kinematics.

CONCLUSIONS

Visual and auditory cueing and the treadmill training are effective interventions for FOG and gait impairments in PD patients (evidence level A- according to the European Federation of Neurological Societies). Tactile cues and other specific therapies targeting FOG are probably effective but need further studies.

Speed-Interactive Pedaling Training Using Smartphone Virtual Reality Application for Stroke Patients: Single-Blinded, Randomized Clinical Trial

This study aimed to investigate the effects of speed-interactive pedaling training (SIPT) using a smartphone virtual reality application to improve lower limb motor function, trunk sitting balance, and gait in stroke patients. Forty-two patients who had previously experienced a stroke and could sit independently participated in the study. The subjects were assigned to the SIPT group (n = 21) and the control group (n = 21). The SIPT group had cycle training with SIPT for 40 min a day, five days a week, in a six-week period, in addition to conventional therapy. The control group had cycle training without SIPT and conventional therapy. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and spatiotemporal parameters of gait were used to assess the changes in lower extremity function, the static balance of sitting, the dynamic balance of sitting, and gait ability after the intervention. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and gait ability in the SIPT group were significantly better compared to that of the control group (p < 0.05). Based on this result, we propose that SIPT, which improves function, balance, and gait, could be used as an effective training method to improve patients’ functional activities in the clinical setting. The results of this study suggest that SIPT could be used as an effective training method to restore a patient’s function by improving trunk balance and motor function.

Parkinson's disease does not alter automatic visual-motor coupling in postural control

This study examined the coupling between visual information and body sway in patients with Parkinson's disease (PD) compared with healthy controls. Postural control performance was compared between 14 patients with PD (age: 69.6 ± 8.8 years - stages 1-3 of the Hoehn and Yahr scale) and 14 healthy control participants (age: 68.6 ± 3.0 years). Participants stood upright in a moving room that remained motionless or continuously oscillated in the anterior-posterior direction. Ten trials were performed in the following conditions: no movement of the room (1 trial) and with the room moving at frequencies of 0.1, 0.17, and 0.5 Hz (3 trials each frequency). Body sway and moving room displacement were recorded. The results indicated that patients with PD displayed larger body sway magnitude in the stationary room condition. Body sway of patients with PD was induced by visual manipulation in all three visual stimulus frequencies, but body sway of patients with PD was less coherent compared to that of the control participants. However, no difference was observed in the visual-body sway coupling structure. These results indicate that patients with PD can unconsciously couple body sway to visual information in order to control postural sway in a similar manner to healthy participants with intact visual-motor coupling for posture control. However, this coupling is marked by greater variability, indicating that people with PD have a motor system with greater inherent noise leading to a more varied behavior.

Usability of Three-dimensional Augmented Visual Cues Delivered by Smart Glasses on (Freezing of) Gait in Parkinson's Disease

External cueing is a potentially effective strategy to reduce freezing of gait (FOG) in persons with Parkinson's disease (PD). Case reports suggest that three-dimensional (3D) cues might be more effective in reducing FOG than two-dimensional cues. We investigate the usability of 3D augmented reality visual cues delivered by smart glasses in comparison to conventional 3D transverse bars on the floor and auditory cueing via a metronome in reducing FOG and improving gait parameters. In laboratory experiments, 25 persons with PD and FOG performed walking tasks while wearing custom-made smart glasses under five conditions, at the end-of-dose. For two conditions, augmented visual cues (bars/staircase) were displayed via the smart glasses. The control conditions involved conventional 3D transverse bars on the floor, auditory cueing via a metronome, and no cueing. The number of FOG episodes and percentage of time spent on FOG were rated from video recordings. The stride length and its variability, cycle time and its variability, cadence, and speed were calculated from motion data collected with a motion capture suit equipped with 17 inertial measurement units. A total of 300 FOG episodes occurred in 19 out of 25 participants. There were no statistically significant differences in number of FOG episodes and percentage of time spent on FOG across the five conditions. The conventional bars increased stride length, cycle time, and stride length variability, while decreasing cadence and speed. No effects for the other conditions were found. Participants preferred the metronome most, and the augmented staircase least. They suggested to improve the comfort, esthetics, usability, field of view, and stability of the smart glasses on the head and to reduce their weight and size. In their current form, augmented visual cues delivered by smart glasses are not beneficial for persons with PD and FOG. This could be attributable to distraction, blockage of visual feedback, insufficient familiarization with the smart glasses, or display of the visual cues in the central rather than peripheral visual field. Future smart glasses are required to be more lightweight, comfortable, and user friendly to avoid distraction and blockage of sensory feedback, thus increasing usability.

Acute and Chronic Effect of Acoustic and Visual Cues on Gait Training in Parkinson's Disease: A Randomized, Controlled Study

In this randomized controlled study we analyse and compare the acute and chronic effects of visual and acoustic cues on gait performance in Parkinson's Disease (PD). We enrolled 46 patients with idiopathic PD who were assigned to 3 different modalities of gait training: (1) use of acoustic cues, (2) use of visual cues, or (3) overground training without cues. All patients were tested with kinematic analysis of gait at baseline (T0), at the end of the 4-week rehabilitation programme (T1), and 3 months later (T2). Regarding the acute effect, acoustic cues increased stride length and stride duration, while visual cues reduced the number of strides and normalized the stride/stance distribution but also reduced gait speed. As regards the chronic effect of cues, we recorded an improvement in some gait parameters in all 3 groups of patients: all 3 types of training improved gait speed; visual cues also normalized the stance/swing ratio, acoustic cues reduced the number of strides and increased stride length, and overground training improved stride length. The changes were not retained at T2 in any of the experimental groups. Our findings support and characterize the usefulness of cueing strategies in the rehabilitation of gait in PD.

Physiotherapy for Parkinson's disease: a comparison of techniques

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.

Physiotherapy versus placebo or no intervention in Parkinson's disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Physiotherapy intervention in Parkinson's disease: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of physiotherapy compared with no intervention in patients with Parkinson's disease.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Literature databases, trial registries, journals, abstract books, and conference proceedings, and reference lists, searched up to the end of January 2012.

REVIEW METHODS

Randomised controlled trials comparing physiotherapy with no intervention in patients with Parkinson's disease were eligible. Two authors independently abstracted data from each trial. Standard meta-analysis methods were used to assess the effectiveness of physiotherapy compared with no intervention. Tests for heterogeneity were used to assess for differences in treatment effect across different physiotherapy interventions used. Outcome measures were gait, functional mobility and balance, falls, clinician rated impairment and disability measures, patient rated quality of life, adverse events, compliance, and economic analysis outcomes.

RESULTS

39 trials of 1827 participants met the inclusion criteria, of which 29 trials provided data for the meta-analyses. Significant benefit from physiotherapy was reported for nine of 18 outcomes assessed. Outcomes which may be clinically significant were speed (0.04 m/s, 95% confidence interval 0.02 to 0.06, P<0.001), Berg balance scale (3.71 points, 2.30 to 5.11, P<0.001), and scores on the unified Parkinson's disease rating scale (total score -6.15 points, -8.57 to -3.73, P<0.001; activities of daily living subscore -1.36, -2.41 to -0.30, P=0.01; motor subscore -5.01, -6.30 to -3.72, P<0.001). Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the interventions for any outcomes assessed, apart from motor subscores on the unified Parkinson's disease rating scale (in which one trial was found to be the cause of the heterogeneity).

CONCLUSIONS

Physiotherapy has short term benefits in Parkinson's disease. A wide range of physiotherapy techniques are currently used to treat Parkinson's disease, with little difference in treatment effects. Large, well designed, randomised controlled trials with improved methodology and reporting are needed to assess the efficacy and cost effectiveness of physiotherapy for treating Parkinson's disease in the longer term.