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.
To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.
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.
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.
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.
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.
Plain language summary
Physiotherapy for 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 by monitoring their condition and targeting appropriate treatment. A range of approaches to movement rehabilitation are used, which aim to enhance quality of life by maximising physical ability and minimising problems related to Parkinson’s over the whole course of the disease.
Only randomised controlled trials were included in this review. In these studies,a group of participants were given physiotherapy intervention and were compared with another group of participants, who did not receive physiotherapy. Participants were assigned to a group in random fashion so a fair test was established. Thirty-nine randomised trials involving 1827 participants were identified as suitable for this review. The quality of the trials was not high because in many, methods were not reported adequately and blinding was not feasible. These trials assessed various physiotherapy interventions, so the trials were grouped according to the type of intervention being used (i.e. general physiotherapy, exercise, treadmill training, cueing, dance, or martial arts).
Improvement in all walking outcomes (except the 10- or 20-metre walk test) was noted with physiotherapy intervention. However, these improvements were significant only for walking speed, walking endurance, and freezing of gait. Mobility and balance also improved with a physiotherapy intervention, with significant improvements reported in one test of mobility (the Timed Up & Go test, which times how long it takes a person to get up from a chair, walk a certain distance, then walk back to the chair and sit down) and in two tests of balance (one assessing how far a person can reach before he or she loses balance (Functional Reach Test) and another assessing multiple aspects of balance (Berg Balance Scale)). Clinician-rated disability, using the Unified Parkinson’s Disease Rating Scale (UPDRS), was also improved with physiotherapy intervention. No difference was observed between the two groups in falls or patient-rated quality of life. One study reported that adverse events were rare; no other studies reported data on this outcome. When the different physiotherapy interventions were compared, no evidence suggested that treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.
This review provides evidence of the short-term benefit of physiotherapy for the treatment of PD. Although most observed differences were small, improvements in walking speed, balance with the Berg Balance Scale, and clinician-rated disability using the UPDRS were of a size that patients may consider them to be important. These benefits should be interpreted with caution because of the quality of the included trials, and the lack of common assessment of treatment effects. This affected the quantity of data that we could use for analysis.