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Review
. 2013 Sep 10;2013(9):CD002817.
doi: 10.1002/14651858.CD002817.pub4.

Physiotherapy versus placebo or no intervention in Parkinson's disease

Claire L Tomlinson  1 , Smitaa Patel, Charmaine Meek, Clare P Herd, Carl E Clarke, Rebecca Stowe, Laila Shah, Catherine M Sackley, Katherine H O Deane, Keith Wheatley, Natalie Ives
Affiliations
Review

Physiotherapy versus placebo or no intervention in Parkinson's disease

Claire L Tomlinson et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

Carl Clarke, Natalie Ives, Charmaine Meek, Smitaa Patel, Catherine Sackley, and Keith Wheatley are recruiting or are involved in the running of the UK PD REHAB trial.

Figures

1
1
Study PRISMA flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
2‐ or 6‐Minute walk test (m). Meek 2010 contributed to 2‐minute walk test. Hackney 2009, Schilling 2008, and Schenkman 1998 contributed to 6‐minute walk test.
5
5
10‐ or 20‐m walk test (s). Kurtais 2008 contributed to 20‐m walk test. Meek 2010, Schenkman 1998, and Stozek 2003 contributed to 10‐m walk test.
6
6
Speed (m/s).
7
7
Forest plot of comparison: 1 Gait Outcomes, outcome: 1.7 Freezing of Gait Questionnaire.
8
8
Timed Up & Go (s).
9
9
Functional Reach (cm).
10
10
Berg Balance Scale.
11
11
UPDRS － total.
12
12
UPDRS － ADL. Earhart 2010, MDS‐UPDRS.
13
13
UPDRS － Motor. Earhart 2010, MDS‐UPDRS.
1.1
1.1. Analysis
Comparison 1 Gait Outcomes, Outcome 1 2 or 6 Minute Walk Test (m).
1.2
1.2. Analysis
Comparison 1 Gait Outcomes, Outcome 2 10 or 20m Walk Test (s).
1.3
1.3. Analysis
Comparison 1 Gait Outcomes, Outcome 3 Speed (m/s).
1.4
1.4. Analysis
Comparison 1 Gait Outcomes, Outcome 4 Cadence (steps/min).
1.5
1.5. Analysis
Comparison 1 Gait Outcomes, Outcome 5 Stride Length (m).
1.6
1.6. Analysis
Comparison 1 Gait Outcomes, Outcome 6 Step Length (m).
1.7
1.7. Analysis
Comparison 1 Gait Outcomes, Outcome 7 Freezing of Gait Questionnaire.
2.1
2.1. Analysis
Comparison 2 Functional Mobility and Balance Outcomes, Outcome 1 Timed Up & Go (s).
2.2
2.2. Analysis
Comparison 2 Functional Mobility and Balance Outcomes, Outcome 2 Functional Reach (cm).
2.3
2.3. Analysis
Comparison 2 Functional Mobility and Balance Outcomes, Outcome 3 Berg Balance Scale.
2.4
2.4. Analysis
Comparison 2 Functional Mobility and Balance Outcomes, Outcome 4 Activity Specific Balance Confidence.
3.1
3.1. Analysis
Comparison 3 Falls, Outcome 1 Falls Efficacy Scale.
4.1
4.1. Analysis
Comparison 4 Clinician‐Rated Disability, Outcome 1 UPDRS ‐ Total.
4.2
4.2. Analysis
Comparison 4 Clinician‐Rated Disability, Outcome 2 UPDRS ‐ Mental.
4.3
4.3. Analysis
Comparison 4 Clinician‐Rated Disability, Outcome 3 UPDRS ‐ ADL.
4.4
4.4. Analysis
Comparison 4 Clinician‐Rated Disability, Outcome 4 UPDRS ‐ Motor.
5.1
5.1. Analysis
Comparison 5 Patient‐Rated Quality of Life, Outcome 1 PDQ‐39 Summary Index.
5.2
5.2. Analysis
Comparison 5 Patient‐Rated Quality of Life, Outcome 2 PDQ‐39 Mobility.
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