Physiotherapy For Parkinsons

Physiotherapy for Parkinsons disease: a comparison of techniques (Review)
Deane K, Jones DE, Ellis-Hill C, Clarke CE, Playford ED, Ben-Shlomo Y
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1 http://www.thecochranelibrary.com
Physiotherapy for Parkinsons disease: a comparison of techniques (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS HEADER . . . . . . . . . . ABSTRACT . . . . . . . . . PLAIN LANGUAGE SUMMARY . BACKGROUND . . . . . . . OBJECTIVES . . . . . . . . METHODS . . . . . . . . . RESULTS . . . . . . . . . . DISCUSSION . . . . . . . . AUTHORS CONCLUSIONS . . ACKNOWLEDGEMENTS . . . REFERENCES . . . . . . . . CHARACTERISTICS OF STUDIES DATA AND ANALYSES . . . . . WHATS NEW . . . . . . . . HISTORY . . . . . . . . . . CONTRIBUTIONS OF AUTHORS DECLARATIONS OF INTEREST . SOURCES OF SUPPORT . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 3 3 3 4 10 12 13 13 15 23 23 23 23 23 23 24
[Intervention Review]
Physiotherapy for Parkinsons disease: a comparison of techniques

Katherine Deane2 , Diana E Jones3 , Caroline Ellis-Hill4 , Carl E Clarke1 , E Diane Playford5 , Yoav Ben-Shlomo6
1 Department of Neurology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK. 2 Institute of Health
& Society, Newcastle University, Newcastle-upon-Tyne, UK. 3 School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK. 4 Health and Rehabilitation Research Unit, University of Southampton, Southampton, UK. 5 Directorate of Musculoskeletal and Rehabilitational Services, The National Hospital for Neurology and Neurosurgery, London, UK. 6 Dept of Social Medicine, Canynge Hall, Bristol, UK Contact address: Carl E Clarke, Department of Neurology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham, West Midlands, B18 7QH, UK. c.e.clarke@bham.ac.uk. Editorial group: Cochrane Movement Disorders Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009. Review content assessed as up-to-date: 28 November 2000. Citation: Deane K, Jones DE, Ellis-Hill C, Clarke CE, Playford ED, Ben-Shlomo Y. Physiotherapy for Parkinsons disease: a comparison of techniques. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD002815. DOI: 10.1002/14651858.CD002815. Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT Background Despite optimal medical and surgical therapies for Parkinsons disease, patients develop progressive disability. The role of the physiotherapist is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. What form of physiotherapy is most effective in the treatment of Parkinsons disease remains unclear. Objectives 1. To compare the efcacy and effectiveness of novel physiotherapy techniques versus standard physiotherapy in patients with Parkinsons disease. Standard physiotherapy is dened as the type of therapy that the physiotherapist would usually use to treat Parkinsons disease. 2. To compare the efcacy and effectiveness of one physiotherapy technique versus a second form of physiotherapy. Search strategy Relevant trials were identied by electronic searches of MEDLINE, EMBASE, CINAHL, ISI-SCI, AMED, MANTIS, REHABDATA, REHADAT, GEROLIT, Pascal, LILACS, MedCarib, JICST-EPlus, AIM, IMEMR, SIGLE, ISI-ISTP, DISSABS, Conference Papers Index, Aslib Index to Theses, the Cochrane Controlled Trials Register, the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR; and examination of the reference lists of identied studies and other reviews. Selection criteria Only randomised controlled trials (RCT) were included. Data collection and analysis Data was abstracted independently by KD and CEH and differences settled by discussion.
Physiotherapy for Parkinsons disease: a comparison of techniques (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1
Main results Seven trials were identied with 142 patients. All used small numbers of patients and the method of randomisation and concealment of allocation was poor or not stated in all of the trials. These methodological problems could potentially lead to bias from a number of sources. The methods of physiotherapy varied so widely that the data could not be combined. Authors conclusions Considering the small number of patients examined, the methodological aws in many of the studies and the possibility of publication bias, there is insufcient evidence to support or refute the efcacy of any given form of physiotherapy over another in Parkinsons disease. Another Cochrane review, Physiotherapy for patients with Parkinsons Disease, found that there was insufcient evidence to support or refute the efcacy of physiotherapy compared to no physiotherapy in Parkinsons disease. A wide range of physiotherapy approaches were used in these studies and a survey of UK physiotherapists conrmed that they also use an eclectic combination of techniques in the treatment of Parkinsons disease (Plant 1999). Therefore a consensus must be found as to best practice physiotherapy for Parkinsons disease. The efcacy of standard physiotherapy should be proved rst before examining variations in physiotherapy methods. Therefore large well designed randomised controlled trials are needed to judge the effect of physiotherapy in Parkinsons disease. After this large RCTs are needed to demonstrate the most effective form of physiotherapy in Parkinsons disease. Outcome measures with particular relevance to patients, carers, physiotherapists and physicians should be chosen and the patients monitored for at least 6 months to determine the duration of any effect. The trials should be reported according to CONSORT guidelines (CONSORT 1996).
PLAIN LANGUAGE SUMMARY In spite of the best medical and surgical treatments for Parkinsons disease, patients develop signicant physical problems. Physiotherapists aim to enable people with Parkinsons disease to maintain their maximum level of mobility, activity and independence through the monitoring of their condition and the targeting of the appropriate physical treatment. A range of approaches to movement rehabilitation, which with education and support are employed to maximise functional ability, minimise secondary complications and enhance quality of life over the whole course of the disease. This review will compare the benets of one form of physiotherapy versus another for people with Parkinsons disease. Relevant trials were identied by electronic searches of 21 medical literature databases, various registers of clinical trials and an examination of the reference lists of the identied studies and other reviews. Only randomised controlled trials were included in this review. These were studies where two groups of patients were compared, each group of patients receiving a different form of physiotherapy. The patients were assigned to each of the two groups in a random fashion to reduce the potential for bias. Data from the selected trials were extracted independently by two reviewers and differences settled by discussion. Seven trials were found comparing two forms of physiotherapy in a total of 142 patients. The quality of the trials methods was variable with all the studies failing in at least one critical area. The methods and outcome measures varied so much that the results of the individual trials could not be combined. Considering the small number of patients and the methodological aws in many of the studies, there is insufcient evidence to support the use of one form of physiotherapy over another for the treatment of Parkinsons disease. Another Cochrane review that examined the efcacy of physiotherapy versus placebo (sham) therapy (Physiotherapy for patients with Parkinsons Disease) concluded that there was insufcient evidence to support or refute the efcacy of physiotherapy in Parkinsons disease. The benets of standard physiotherapy should be proved rst before examining variations in physiotherapy methods. Therefore large well designed randomised controlled trials (RCTs) are needed to judge the effect of physiotherapy in Parkinsons disease. After this, large RCTs are needed to demonstrate the most effective form of physiotherapy in Parkinsons disease. The design of the trials should minimise bias and be reported fully using CONSORT guidelines. Outcome measures with particular relevance to patients, their carers, physiotherapists and physicians should be chosen and the patients followed for at least 6 months to determine the duration of any improvement.
Physiotherapy for Parkinsons disease: a comparison of techniques (Review) Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2
BACKGROUND
The modern management of Parkinsons disease centres on pharmacological therapy, principally with levodopa combined with a dopa decarboxylase inhibitor. However it is now recognised that in long-term usage, levodopa precipitates motor complications such as involuntary movements and uctuations in response. In spite of optimal pharmacological therapy, the underlying disease continues to progress. All existing treatments provide only symptomatic benet with no conclusive evidence that they are neuroprotective. The disabilities due to Parkinsons disease occur at all stages of the disease and impact upon the patients quality of life. Signicant disability can occur in the early stages of the disease with patients becoming dependent for washing, dressing, eating and other activities of daily living. The severity of these disabilities usually increases with disease duration. It has been suggested that physiotherapy can improve the abilities of patients with Parkinsons disease as an adjunct to drug therapy (Hildick-Smith 1987). The purpose of physiotherapy in Parkinsons disease is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. This working denition of physiotherapy for Parkinsons disease has been generated from the results of an evaluation of best practice physiotherapy in the UK (Plant 1999). Physiotherapy for Parkinsons disease covers a number of different treatment techniques, largely centred on active exercises and re-education of mobility. A postal questionnaire of 261 Parkinsons patients in touch with the Parkinsons Disease Society in 1982 found that 29% had seen a physiotherapist (Oxtoby 1982). In Mutch et als 1986 community-based study of 267 patients, only 7% had seen a physiotherapist (Mutch 1986). A survey of 72 Parkinsons patients attending a movement disorder clinic in 1995 found that 29% had seen a physiotherapist (Clarke 1995). Finally, a members survey of the Parkinsons Disease Society of the United Kingdom with a total of 1,693 respondents found that 27% of respondents had been assessed or treated by a physiotherapist (Yarrow 1999). These low referral rates do not accord with most published guidelines for the management of Parkinsons disease. Possible explanations for this include limited access due to high general demands on physiotherapy services, perception of lack of benet and difculties with interpretation of trials due to awed methodology. This review of randomised clinical trials aims to compare the efcacy and effectiveness of novel physiotherapy techniques versus standard physiotherapy in patients with Parkinsons disease. It will also compare the efcacy and effectiveness of one novel physiotherapy technique versus a second novel form of physiotherapy. Another Cochrane review assesses the effect of active physiotherapy compared with placebo (Deane). To compare the efcacy and effectiveness of novel physiotherapy techniques versus standard physiotherapy in patients with Parkinsons disease. To compare the efcacy and effectiveness of one physiotherapy technique versus a second form of physiotherapy.
METHODS
Criteria for considering studies for this review
Types of studies All randomised controlled trials comparing two types of physiotherapy were considered for inclusion in the study. Both random and quasi-random methods of allocation were allowed. Types of participants Patients with a diagnosis of Parkinsons disease (as dened by the study authors). Any duration of Parkinsons disease. All ages. Any drug therapy. Any duration of treatment. Types of interventions One physiotherapy technique versus a second. Types of outcome measures 1. Motor impairment, (a) Totaled (e.g. United Parkinsons Disease Rating Scale (UPDRS) motor score, part III). (b) Individual measures of tremor, rigidity etc. (c) Timed tests of activities (e.g. walking velocity). 2. Activities of daily living (e.g. UPDRS Activities of Daily Living (ADL) score, part II). 3. Handicap and quality of life measures, both disease specic, (e.g. Parkinsons Disease Questionnaire -39, PDQ-39), and generic, (e.g. Short Form - 36, SF-36). 4. Depression rating scales (e.g. Hospital Anxiety and Depression Scale, HADS). 5. Adverse effects. 6. Carer outcomes (e.g. Carer strain index). 7. Economic analysis. We will examine both short term and long term (e.g. 6-12 months) effects of the intervention.
3
OBJECTIVES
Search methods for identication of studies

1. The review is based on the search strategy of the Movement Disorders Group and also the following more general search strategy: a. Physiotherapy OR physical therapy OR exercise OR rehabilitation b. Parkinson OR Parkinsons disease OR Parkinsonism c. #a AND #b Relevant trials were identied by electronic searches of general biomedical and science databases: MEDLINE (1966-2000), EMBASE (1974-2000), CINAHL (1982-2000), ISI-SCI ((19812000); rehabilitation databases: AMED (1985-2000), MANTIS (1880-2000), REHABDATA (1956-2000), REHADAT, GEROLIT (1979-2000); English language databases of foreign language research and third world publications: Pascal (19842000), LILACS (1982-2000), MedCarib (17th Century-2000), JICST-EPlus (1985-2000), AIM (1993-2000), IMEMR (19842000) and hand searching of appropriate journals. Relevant trials were included on the Groups specialised register of randomised controlled trials. 2. The Cochrane Controlled Trials Register, the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR, were also searched for relevant trials. 3. The reference lists of located trials and review articles were searched. 4. Grey literature (e.g. conference abstracts, theses and internal reports) were searched. This included The XIII International Congress on Parkinsons disease (1999), The International Congress of Parkinsons Disease and Movement Disorders (1990, 92, 94, 96, 97, 98), The American Academy of Neurology 51st annual meeting (1999). The following grey literature databases were searched: SIGLE (1980-2000), ISI-ISTP (1982-2000), DISSABS (1999-2000), Conference Papers Index (1982-2000) and Aslib Index to Theses (1970-2000). 5. National and regional professional associations were asked to search for relevant trials. Requests for help were placed on bulletin boards on their web pages. 6. Universities and colleges that carry out degree courses in physiotherapy were asked to search for any relevant unpublished projects. 7. Patient support groups (the Parkinsons Disease Society etc.)
were asked if they had funded any relevant trials. Requests for help were placed on bulletin boards on their web pages. Further details on this search strategy are available in the Groups module within the Cochrane library (www.cochrane.org). This includes explanations of the acronyms, sources and web sites.
Data collection and analysis

The authors independently assessed the studies identied by the search strategy. Disagreements about inclusions were resolved by discussion. The full papers were assessed for methodological quality by recording the method of randomisation and blinding, whether an intention-to-treat analysis was used and the number of patients lost to follow up. Eligible data was abstracted by two authors (KD and CEH) onto standardised forms independently, checked for accuracy and amalgamated. Disagreements about inclusions were resolved by discussion. Ordinal data such as UPDRS motor subsection scores were treated as if they were interval data (i.e. continuous), where we could make an assumption of equality of intervals e.g. UPDRS part II ADL and part III motor. Although we recognise that this is controversial, Popham 1973 reported that when parametric procedures have been employed with ordinal data, they rarely distort a relationship between variables which may be present in the data. Other ordinal data such as UPDRS complications of therapy subsection (and thus total UPDRS) is based on summation of the scores from a series of dichotomous questions (which are weighted equally), there is no equality of interval and so this data was analysed in a nonparametric fashion.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies. See Table: Characteristics of Included Studies and Table 1: Key Characteristics of Included Studies.
Table 1. Key Characteristics of Included Studies
Study
Number of Mean Age Patients
Mean Duration Hoehn & Yahr Score
Location
Type Physio.
of Additional therapy?
Individual or Group?
Table 1. Key Characteristics of Included Studies
(Continued)
Hirsch 96
17
74
2.0
UnspecOutpatients ied time/10 weeks 14 units / 5 Outpatients weeks urs/6 weeks Outpatients
Strength & None balance Vs balance Bobath PNF Vs None
Individual
Homann 98 16
n/a
n/a
Individual
Marchese 2000 Mohr 96
20
66
2.4
Cued Vs None Standard Behavioural None (inc. cues) Vs standard Karate Vs None standard Visual cues None Vs auditory cues Auditory None cues Vs standard
Individual
41
62
2.1
30 hours/10 Outpatients weeks
Group
Palmer 86
14
65
2.4
36 hours/12 Outpatients weeks Unspecied Outpatients
Group
Shiba 99
65
n/a
Individual
Thaut 96
26
72
2.5
10.5 hours/3 Home weeks
Individual
TOTAL
142
6 5 Cued trials Outpatients; 1 Home
5 Individual; 2 group.
Seven trials were found that compared one form of physiotherapy with another in a total of 142 Parkinsonian patients. TRIAL DESIGN All of the trials were single centre studies. Six of the trials were parallel group design, whilst Shiba 99 was a cross-over trial. Physiotherapy was carried out for 10.5-36 hours over 3-12 weeks. However it should be noted that three of the trials did not specify the number of hours of treatment given. One trial (Shiba 99) has recently been published in abstract form. Data from the trial was therefore limited and the number of weeks over which the physiotherapy was administered was not specied. None of the trials specied the intensity of the physiotherapy provided. PARTICIPANTS The patients were an average of 67 years old. In ve out of the seven trials the treatment groups in each individual trial were internally
comparable. In Shiba 99 the data was unavailable, in Homann 98 only data for the whole patient population of this three arm trial were available. Only two trials specied individual physical impairments as part of their inclusion criteria. Hirsch 96 required patients to have a history of falls or unsteadiness, or to have weak muscles in the legs. Thaut 96 required their patients to have significant gait decits but be able to walk without physical assistance. INTERVENTIONS Six out of seven trials were carried out in outpatient settings (this included research clinics). Thaut 96s therapy was carried out at home with the assessments being carried out in a laboratory setting. Four of the trials (Marchese 2000, Homann 98, Shiba 99 & Thaut 96) carried out physiotherapy interventions with individual patients. The remaining three interventions (Hirsch 96, Mohr 96 & Palmer 86) involved group work, although Mohr 96 used
unequally size groups (3-4 patients in novel groups versus 5-7 patients in the standard group). The therapy was conducted by a physiotherapist in only one trial (Thaut 96). Mohr 96 used clinical psychologists. Palmer 86 used a corrective therapist and a rehabilitation nursing student with a black belt in Karate. Hirsch 96 used volunteers from the Physical Education and Human Movement Sciences department at Florida State University and the carers of the patients all of whom were trained by the principle investigator, but it was unclear what his qualications were. It was unclear in the remaining three trials ( Marchese 2000, Homann 98, Shiba 99 ) what the qualications were of those conducting the therapy. Five of the trials used visual or auditory cues to promote movement in the patients, however the amount of emphasis placed on the cueing and the method of physiotherapy against which it was compared varied signicantly. Overall the methods of physiotherapy varied so signicantly that the studies cannot be combined and so will be examined individually. Hirsch 96 Hirsch 96 trained their patients for leg strength and balance and compared these patients to a group that received balance training only. Homann 98 Homann 98 used proprioceptive neuromuscular facilitation (PNF) which uses cues as part of the technique and directed the therapy at spinal mobility. This was compared to a Bobath physiotherapy program focusing on proprioceptive skills to improve posture and gait. The description of the methods used was limited as this study has only been published in abstract form. Marchese 2000 Table 2. Methodological Quality of Included Studies
Marchese 2000 carried out an individual physical rehabilitation program including visual and auditory cues and compared these patients to another group that underwent a similar movement rehabilitation program but without the cues. Mohr 96 Mohr 96s novel group underwent behavioural therapy that included relaxation techniques, role playing and motor training using external cues (visual and auditory). These patients were compared with a standard group that were given breathing and physical exercises (without cues), short relaxation and discussion of disease-related problems. The two methods were described as being distinct from one another. Palmer 86 Palmer 86 trained their patients in upper body Karate exercises and compared these patients to a group that performed stretch exercises designed for Parkinsons patients. Shiba 99 Shiba 99s study had a cross-over design. Group I had visually stimulated gait training followed by auditory stimulated gait training. Group II had auditory stimulated gait training rst. There was one week between each training regime. Thaut 96 Thaut 96 gave auditory stimulated gait training using three different tempos of music that increased in pace as the study progressed. The standard group were instructed to walk for 30 min/day at three different paces (normal, quick, fast).
Risk of bias in included studies

See Table 2: Methodological Quality of Included Trials and Table 1: Key Characteristics of Included Trials.
Study
Specied El- Randomisa- ConcealSimilarity at WithMissing Val- Cointerven- Blinded asigibility Cri- tion Method ment of Al- Baseline drawals De- ues tions Con- sessors teria location scribed stant (e.g. drugs) A A A A B A B A B A C A A C A A B A A C B A
Hirsch 96
Homann 98 A Marchese 2000 Mohr 96 A
A
6
Table 2. Methodological Quality of Included Studies
(Continued)
Palmer 86 Shiba 99 Thaut 96
A A A KEY: A: Adequate B: Unclear (not stated) C: Inadequate
B B C KEY: A: Good B: Unclear (not stated) C: Weak (eg alternate allocation)
B B B KEY: A: Adequate B: Unclear (not stated) C: Inadequate
A B A KEY: A: Good B: Unclear (not stated) C: Poor
A A A KEY: A: Good, <10% B: Unclear (not stated) C: Poor, >10%
A A A KEY: A: Good, <10% B: Unclear (not stated) C: Poor, >10%
A B A KEY: A: Constant B: Unclear (not stated) C: Allowed Variation
A B A KEY: A: Adequate B: Unclear (not stated) C: Inadequate
METHOD OF RANDOMISATION AND CONCEALMENT OF ALLOCATION Homann 98 put the patients names into alphabetical order before assigning them a random number. Theoretically if the alphabetical list was open to the person applying the random number list, he or she could miss out the next random number if it put the patient into a group s/he did not want and go on to the next random number that did. Hirsch 96 and Marchese 2000 used computer generated random number tables to randomise but did not state how the allocation was concealed. Also during the course of the Hirsch 96 study one patient changed therapy group and was included in the balance groups data although they were originally allocated to the balance and strengthening group. This could have introduced selection and attrition bias. Thaut 96 used a random draw method. Whilst this method is random it is susceptible to tampering. The remaining three studies gave no information as to their method of randomisation or concealment of allocation so selection bias cannot be excluded. ELIGIBILITY CRITERIA The eligibility criteria for the trials were very broad and varied considerably between trials. Only one trial (Homann 98) used strict criteria for the diagnosis of idiopathic Parkinsons disease. NUMBERS OF PATIENTS A total of 142 patients were examined in seven studies. With such a small number of patients it is unlikely that they were truly representative of the Parkinsonian population as a whole. There is a strong possibility of selection bias with such small numbers. Over-
all only 42 of the 126 patients whose gender was specied were female (33%), this could introduce difculty when trying to apply the results of these trials to the general Parkinsons population, where the prevalence is approximately equal (Tanner 1996). SIMILARITY AT BASELINE A description of the baseline characteristics of the patients is important to decide whether the results are generalizable and to compare characteristics of the two groups to ensure that the randomisation was successful. Considering the small number of patients in all of the studies, the likelihood of an unequal distribution of patients is high. The baseline characteristics of the total population studied, rather than for each treatment group, were given in Homann 98 so no assessment could be made between the therapy groups. The gender of the patients in each therapy group was only stated in three trials, Hirsch 96, Mohr 96 and Thaut 96. The distribution of males and females was fairly even in these three trials. The age of the patients was fairly evenly matched in each therapy group in the ve trials in which it was given. Although the Hoehn and Yahr scale is a crude way of assessing disease severity it does give a rough idea of what sort of patients were treated in the trials. As the Hoehn and Yahr scale is not continuous the median should be used, however most authors quote the mean. The mean Hoehn and Yahr score was given for each of the therapy groups in four of the trials (Marchese 2000, Mohr 96, Palmer 86 and Thaut 96), and was fairly evenly matched. DESCRIPTION OF PHYSIOTHERAPY
The methods of physiotherapy used were generally described only in a very broad manner. It would have been useful if a fuller description of the method of therapy had been given so that it would be easier to compare these trial with others. However further details of the exact protocol used was available from Thaut 96 on request. In particular the time spent with the therapist was not specied in 3 of 6 trials (Marchese 2000, Hirsch 96 and Shiba 99), although it should be noted that one of these studies (Shiba 99) was only available to us as an abstract. However lacking this vital piece of information it would be hard to reproduce these studies. Mohr 96 used unequally sized groups (3-4 patients in novel therapy vs. 5-7 patients in the standard group). This could have led to performance bias, in that the patients in the smaller novel therapy groups would have had more attention from the therapist than those in the larger standard therapy groups. OUTCOME MEASURES A wide variety of outcome measures were used in these trials. A discussion of their reliability, sensitivity and clinical relevance is given in the Discussion section. The patients were followed for a maximum of 8 weeks post-therapy, thus the long-term persistence of the effect of physiotherapy is hard to determine. DATA AND ITS ANALYSIS Four studies analysed their data on an intention-to-treat basis. However as none of the trials stated the basis of their data analysis, this is more a reection of the fact that these four trials had no dropouts and therefore by default the data is analysed on an intentionto-treat basis. The data were analysed on a per protocol basis in Hirsch 96, and it was unclear how the data in Shiba 99 and Mohr 96 were analysed. Hirsch 96 violated the random allocation when one of the patients randomised to the novel (combined therapy) group developed an inguinal hernia 2 weeks into the trial. In the opinion of the authors this was not an adverse event due to the physiotherapy. He was unable to carry out the strengthening portion of the combined therapy and so was re-allocated to the balance therapy alone group (standard). No numerical data were available for the cross-over trial of Shiba 99. If it had been data from the rst arm of the trial would be required so as to remove the possibility of carry-over effects. Only Thaut 96 specied a primary outcome (walking velocity on at and inclined surfaces). Examining multiple outcomes carries the risk of multiple analyses and a higher risk of nding spurious but statistically signicant results. Hirsch 96, Marchese 2000, Palmer 86 and Thaut 96 statistically compared the change in a given outcome measure (i.e. score after therapy - score at baseline) between the two therapy groups (i.e. change due to therapy A vs change due to therapy B). The remaining trials statistically compared the change in an outcome for each
therapy group individually over time. This means that these trials did not examine whether one form of physiotherapy is better than another, only that improvements occurred after a given therapy. BLINDING OF PARTICIPANTS It is practically impossible to blind the patients and the therapists in trials comparing the efcacy of one form of physiotherapy with another. This leaves such trials open to performance and attrition bias. However the assessors were blinded in Marchese 2000, Mohr 96 and Palmer 86 so detection bias is unlikely in these three studies. Thaut 96 used a computerised gait analysis system and so detection bias is unlikely in this study. However the assessors were unblinded in Hirsch 96, and it was not stated in Shiba 99, so detection bias cannot be excluded in these two studies.
Effects of interventions
Seven trials were identied comparing two forms of physiotherapy with 142 patients in total. There was signicant heterogeneity in both trial design and the outcomes measures used such that the results cannot be combined, so the trials results were examined on an individual quantitative basis. Hirsch 96, Marchese 2000, Palmer 86 and Thaut 96 provided data on the mean change in outcome measures and statistically compared this change across the two arms of the trial. The authors of the other studies provided the mean and SD at baseline and after treatment for each therapy group. We are awaiting advice from the Cochrane Collaboration and other statistical departments on a valid method of calculating the standard deviation of the change from this data. Upon receiving this advice we will update this review. Hirsch 96 Hirsch 96 measured the number of falls during testing conditions. Falls were dened as when the patients used their hands for support or when a stepping strategy was used to avoid a fall. The tests were carried out for 20 seconds for each of six conditions; a combination of the patient standing on a xed or sway-reference surface, with eyes shut, eyes open, or eyes open and the surroundings also sway-referenced. Both methods decreased the number of falls, but statistical analysis was not given. Those patients receiving combined therapy had one less fall under test conditions (i.e. under Equitest conditions) than the balance group immediately after the course of treatment. This difference persisted at the four week follow up. The remainder of the outcomes provided data on the change due to therapy for each of the two groups. However the author did not carry out statistical analysis of the differences between the two forms of physiotherapy. The test conditions described above were used to assess the degree of sway of the patients using Equitest Scores. Only one test condition (sway-referenced support and eyes closed) showed any signicant difference (P<0.05) in favour of the combined balance and strengthening physiotherapy method at the four week follow-up assessment.
8
Unsurprisingly, those patients receiving combined strength and balance training signicantly increased the strength of their leg muscles as compared to the balance training group (P<0.001), a result that persisted at the four week follow-up assessment (P<0.05). The activities of daily living ability (ADL) of the patients was assessed using an ad hoc 18 item questionnaire. The score from this questionnaire was divided into ADL (dressing, toileting, washing etc., 11 items) and Instrumental ADL (cleaning house, preparing food, shopping etc., 7 items). The ADL score did not differ between the two therapy groups. However the Instrumental ADL was signicantly improved by the combined therapy as compared to the balance therapy alone (P<0.05), and this improvement persisted at the four week follow-up (P<0.01). Homann 98 This study was only presented as an abstract. No numerical data were available. Marchese 2000 Data were available for UPDRS mental, motor and ADL subsections in Marchese 2000 at baseline, immediately after therapy and six weeks later. None of the UPDRS subsections detected any signicant difference between the cued and uncued physiotherapy regimes immediately after the course of therapy. However six weeks later UPDRS motor scores for the cued group differed signicantly to those for the uncued group (4.9 points, Mann Whitney p<0.02). None of the other subsections scores detected signicant differences between the two treatments. Mohr 96 This study measured motor impairments using UPDRS motor subsection. A two-way MANOVA revealed a highly signicant difference with post hoc ANOVAs revealing no performance change in the control group whilst the group receiving behavioural therapy showed signicant improvements (F(1,19) = 6.5, p = 0.01). The difference in the change of the mean scores between the groups was 0.21 points in favour of the behavioural therapy. They also measured ne motor control impairment specically in the right and left hands. This was carried out by using the computer-assisted Motor Performance Test Series (MPS). This test allows for the exact quantication of the speed and accuracy of complex arm, hand and nger movements such as following a winding line with a pencil-like instrument. The MPS result includes error scores and reaction times. In order to conduct an overall analysis of the results in this test series, all data were rst converted to zscores (with positive values indicating better performance). Subsequently these z-scores were subjected to MANOVA. When right and left hand performance were compared no reliable interaction was found in the left hand data, but a signicant difference was found for the right hand data. Post hoc ANOVAs showed signicant improvements after treatment only in the behavioural group F(1,19) = 8.1, p = 0.01. The difference in the change of the mean scores between the groups was 0.74 for the right hand and 0.06 for the left hand. It should be noted that all except two patients
(one in each therapy group) were right handed. A two-way MANOVA of the UPDRS-ADL scores showed no signicant difference. The difference in the change of the mean scores between the groups was 0.07 in favour of the behavioural group. Quality of life was measured using a questionnaire about contentment of life, which revealed higher scores after therapy. The difference in the change of the mean scores between the groups was 0.17 points for general contentment of life and 0.02 points for healthrelated contentment of life, both in favour of the behavioural therapy. These differences were not statistically signicant. Patients mood was measured using UPDRS-Mental subsection and the Beck Depression Inventory (BDI). The difference in the change of the mean scores of the UPDRS mental subsection between the groups was 0.13 points in favour of the behavioural therapy. The difference in the change of the mean scores of the BDI between the groups was 0.63 points in favour of the standard therapy. Palmer 86 Palmer 86 administered the Parkinsons Disease Motor Battery along with a variety of tests to assess activities of daily living, grip strength and motor co-ordination. Data was provided on the mean and standard deviation of the change due to therapy. Tremor signicantly decreased in the left arm in the karate group compared to the stretch exercises group (p<0.01). However it should be noted that although not statistically signicant the trend is in the opposite direction for the right arm. The nine-hole pegboard test improved signicantly in both the right (p<0.05) and left (p<0.001) hands in the karate trained group as compared to the stretch group. None of the other measures showed any signicant difference between the two forms of therapy used in this study. Shiba 99 This study was presented as an abstract. No numerical data were available. Thaut 96 Thaut 96 examined gait parameters after walking to a rhythm compared to self-paced walking. Data was provided for the percentage change score means and standard deviations. ANOVA comparisons between the groups revealed signicant differences in improvement in walking velocity over at and inclined surfaces. Post hoc comparisons showed that the rhythmically cued group improved signicantly over the self-paced timing group (Flat: p = 0.03; Incline: p = 0.03). Similar analysis of stride length and cadence showed that changes in stride length did not differ signicantly between the two therapy groups, whilst changes in cadence were signicantly higher in the cued therapy group (p = 0.03). OTHER OUTCOMES None of the studies examined medication dosage, adverse events, carer outcomes or performed any economic analysis of the therapies.
DISCUSSION
PRINCIPAL FINDINGS Seven randomised controlled trials were found comparing two forms of physiotherapy (142 patients). These studies varied signicantly in their methodology so it was deemed inappropriate to combine the results of the studies. Individual studies were too small to demonstrate that any one form of physiotherapy was signicantly better than another.
The trials used insufcient numbers of patients to avoid drawing false negative conclusions and to reduce the possibility of selection bias. It is now generally accepted that quality of life measures should be used as the primary outcome of interest in clinical trials. Only one trial (Mohr 96) used QOL scales, and as only 41 patients were examined in this study there is insufcient data to inform sample size calculations for future trials. The randomisation method used in three trials (Marchese 2000, Hirsch 96 and Homann 98) was computer generated random number tables and a random draw in one study (Thaut 96). The remaining three trials did not state how randomisation was achieved. In all seven trials the concealment of the allocation was inadequate, unclear or not stated. It is vital that eligibility criteria are well dened so that it is understood what sort of a population were treated. For example it is important that the Parkinsons disease accords with the UK Brain Bank Parkinsons Disease criteria (Gibb 1988). This will reduce the likelihood of including patients with Parkinsons plus syndrome which have a signicantly different clinical course compared to idiopathic Parkinsons disease. The eligibility criteria should also dene the severity of the patients eligible to participate, and state clearly any exclusion criteria such as severe arthritis. This would allow an easier assessment of which Parkinsons disease patients the trials results apply to. The physiotherapy methods were poorly described, also the time spent by the therapist with the patient was not specied in four trials. Also the intensity of the therapy was never dened in any of the studies examined. This means that it would be hard to reproduce the studies methodology. It is recognised that physiotherapy methods can be hard to describe and that the methods vary according to the patients needs and abilities. One way to achieve this would be to post further details, even videos, on a journals web site. Only 33% of the patients whose gender was specied were female. This is in contrast to the general population of Parkinsons patients were the prevalence of the disease is equal between the sexes (Tanner 1996). This is a common nding in Parkinsons disease trials but raises the question of whether the results are generalisable to the whole Parkinsons disease population and to women in particular. OUTCOME MEASURES The outcome measures used varied greatly between the trials. The outcome measures used in ve of the seven trials were only assessed at baseline and immediately after therapy. It would have been valuable to know the long-term duration of any improvement following therapy. The outcome measures used must be clinimetrically sound and reliably reect the impact of physiotherapy on the patients life. Motor Impairment: Global Scales:
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Considering the small number of patients examined, the methodological aws in the studies, and the possibility of publication bias, it is unsafe to draw any conclusions regarding the efcacy of any one form of physiotherapy.
Considering the wide range of physiotherapy approaches used in the studies, agreement needs to be found as to standard or optimal physiotherapy for Parkinsons disease.
Large well designed RCTs are needed initially to demonstrate standard physiotherapys efcacy and effectiveness in Parkinsons disease versus placebo. After that individual variations in methods can be compared against this standard, again by using large well designed RCTs. PHYSIOTHERAPY METHODS A wide range of physiotherapy methods were used in these trials, e.g. proprioceptive neuromuscular facilitation, Bobath, Karate, stretches etc. A survey of UK physiotherapists found that there was a consensus that an eclectic combination of therapies offered the best treatment approach in Parkinsons disease (Plant 1999). However work needs to be done in agreeing a standard form of physiotherapy that can then be tested in a trial. This review highlights the fact that there is no trial evidence to support any one form of physiotherapy over another in Parkinsons disease.
METHODOLOGICAL QUALITY Overall the methodological quality of the trials and the standard of the reporting was poor. However it is recognised that four of the seven studies were published before the CONSORT guidelines were published (1996), when trial reporting was not formalised. Two of the studies (Homann 98 and Shiba 99) were only published as abstracts. Although some more data was obtained from some of the authors, greater detail may become available when the full reports are published.
The motor subsection (part III) of the UPDRS is one of the most popular rating scale used in clinical trials in recent years. The UPDRS-Motor subsection combines disability and handicap measures in the same scale. This scale was used in both Marchese 2000 and Mohr 96. Marchese 2000 found that the cued therapy was not signicantly better than uncued physiotherapy immediately after the therapy regime. However when the patients were followed for a further six weeks the cued therapy group differed from the uncued group by 4.9 points (Mann Whitney p<0.02). A difference of ve points is probably clinically useful. Mohr 96 found a smaller change in UPDRS-Motor of 0.21 points in favour of the behavioural therapy. It is unlikely that this difference between the two therapy methods used in this trial is clinically signicant. Motor Impairment: Gait The walk index of patients was calculated in Palmer 86 as the product of the number of seconds required to walk 30 feet multiplied by the number of steps taken by the right foot. This measure showed no signicant difference between the two therapies examined. Individual gait parameters were measured Thaut 96. The change in walking velocity on both at and inclined surfaces and in cadence were signicantly higher in the group that trained walking to a rhythmic piece of music. The changes reported may have clinical signicance, they were between 24-26% improvement. Also the authors reported that all the patients receiving the cued training reported improvements in walking stability, speed and helped their walking in activities of daily life. Motor Impairment: Balance Balance is vital in the prevention of falls which can have a significant impact upon Parkinsons disease patients health. Hirsch 96 measured the number of falls under test conditions. This did not detect any signicant difference between the balance training and the combined balance and leg strengthening. Another measure employed by Hirsch 96 was the degree of sway of the patients under six different conditions designed to test vestibular and proprioceptive components of balance. Only one measure showed signicant improvement in the combined group at the four week follow-up assessment; sway referenced support with eyes closed (P<0.05). This large number of related outcomes may lead to a problem with examining multiple statistical tests at the 95% condence level as 1 in 20 outcomes may be signicant by chance. Re-examining this outcome at the 99% condence level produces a non-signicant result. Motor Impairment: Fine motor control This was assessed in Mohr 96 using a Motor Performance Test Series (MPS). This is an objective measure of Parkinsonian patients ne motor control of their hands. Performance in the MPS correlates highly with motor performance relevant in everyday life, such as handwriting or cutting with a knife and the motor section of UPDRS (Pinter 1992). The changes due to therapy were not
compared statistically between the groups so we are unable to determine the statistical signicance of a difference 0.74 (right hand) and 0.06 (left hand) in favour of the behavioural therapy group. Clinical signicance seems unlikely with such small changes. Palmer 86 used a pursuit score calculated as the number of times in a 50 second period the patient covered a randomly moving dot on an oscilloscope with a photodetector in his outstretched hand to assess ne motor control. This measure did not detect any signicant differences between the two therapy modes used in this study. Palmer 86 used a nine-hole pegboard test to assess dexterity and coordination. Over the three months of the therapy the stretch group got much worse at this test whilst the karate trained group maintained or slightly improved their scores. This difference was signicant for both the right and left hands. However other tests used in this study that could also be said to detect changes in dexterity and coordination such as the Minnesota placing and turning test or the button board showed no signicant differences between the two therapy techniques. Motor impairment: Muscle strength Leg muscle strength was measured in Hirsch 96. The study compared balance training with combined balance and strength training. As the strengthening exercises were all focused on the legs it was not surprising that the combined therapy increased the muscle strength of the legs signicantly more than balance training alone. Grip strength was assessed in Palmer 86 but this did not distinguish between the two therapies used, although both therapies increased the grip strength by about 20%. Activities of Daily Living The UPDRS ADL subsection was designed for use with Parkinsons disease patients and has been validated with this patient population. This scale was used by Marchese 2000 and Mohr 96. Only Marchese 2000 statistically examined the change in means between the two therapy groups. The size of the difference in mean change was small in both studies, between 0.1 (Marchese 2000) and 2.2 points (Mohr 96). It is unlikely this has clinical signicance. Hirsch 96 used a novel 18 point ADL scale for which we have no details on its validity, reliability and sensitivity in Parkinsons disease. The scale was divided into two parts, ADL and instrumental ADL. The Instrumental ADL (7 items) was improved signicantly in the combined balance and strength group as compared to the balance only group. It is hard to determine the clinical signicance of a 3-5 point improvement in this scale. Palmer 86 timed a number of activities of daily living such as putting socks and shoes on and off, putting a shirt on and off and getting up from a chair. None of these measures detected any signicant differences between karate and stretch exercises.
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These tests of ADL can be said to be more an assessment of motor function as they represent an articial situation, e.g. patients would rarely put a shirt on and then take it off immediately. Also the patients did not have access to any aids and adaptations that they might use in real life e.g. Velcro fasteners.
Approximately 75% of patients with Parkinsons disease live with a partner, who is usually of a similar age and may have disabilities of their own (Lloyd 1999). The impact of caring for a person with Parkinsons can be severe (OReilly 1996), and it would be hoped that an intervention such as physiotherapy could have a positive effect on the carers life as well as the patients. Health Economics No health economics analysis of physiotherapy has been performed which precludes an understanding of the economic value of this therapy.
Quality of Life Mohr 96 used a Contentment of Life score to assess general QOL and health related QOL. We have no knowledge of its validity, reliability and sensitivity in Parkinsons disease patients. The change in the means was not analysed between the two therapy groups. Thus it is impossible to determine the statistical signicance of a 0.17 point difference for general contentment of life and a 0.02 point difference for health-related contentment. The clinical signicance of these changes is also impossible to determine. Depression The effectiveness of the therapy could potentially be affected by depression. Depressed patients could be less compliant both during the therapy sessions and also in the practice at home. The therapy itself might affect depression. The patients mood may improve due to the attention they are being paid by the therapist, by getting out of the house and meeting other people. A well designed placebo intervention would control for the non-therapeutic confounders. If the therapy affected the patients physical well-being so that they feel more in control and able to carry out more of their ADL independently, this could improve the patients mood. Also it is important to measure depression as a number of surveys ( Karlsen 1999, GPDS 2000) have shown that depression accounts for a signicant proportion of the reduction in quality of life due to Parkinsons disease. The Beck Depression Index (BDI) is a highly validated and sensitive score to assess depression that has been used in a number of studies of Parkinsons disease patients. The BDI is a 21 item, selfrated inventory covering a wide variety of cognitive, behavioural and somatic aspects of depression. It was used in Mohr 96 but analysis of the mean change between the two groups was not performed. There was a difference of 0.63 points between the groups in favour of standard therapy but the clinical signicance of such a small difference is doubtful. UPDRS mental subsection was used to measure mood in Marchese 2000 and Mohr 96. This subsection consists of only four questions and is often criticised for being too brief. Only two of the questions relate to depression the other two assess dementia and hallucinations. The change of the mean score was compared between the two therapy groups in only Marchese 2000. The small difference seen in Marchese 2000 (0.5 points) is not statistically signicant. Mohr 96 detected a difference of 0.13 points. It is probable that neither difference is clinically signicant. Carer Outcomes
AUTHORS CONCLUSIONS Implications for practice

All of the trials reported that they found one form of physiotherapy superior to another. However the small numbers in all of the trials and the methodological problems present in most studies prevent us from drawing any rm conclusion regarding the superiority of one form of physiotherapy over another in Parkinsons disease.
Implications for research

Considering the small number of patients and the methodological aws in many of the studies, there is insufcient evidence to support the use of one form of physiotherapy over another for the treatment of Parkinsons disease. Another Cochrane review that examined the efcacy of physiotherapy versus placebo or no therapy (Physiotherapy for patients with Parkinsons Disease) concluded that there was insufcient evidence to support or refute the efcacy of physiotherapy in Parkinsons disease. Although a recent survey (Plant 1999) has determined that an eclectic combination of physiotherapeutic methods offers the best treatment of Parkinsons disease, more work needs to be performed to determine the best combination of methods. These then need to be dened in sufcient detail so as to allow the examination of the efcacy of physiotherapy in Parkinsons disease in a large multi-centre trial. The efcacy of standard physiotherapy must be proved rst before examining variations in physiotherapy methods. Therefore large well designed randomised controlled trials are needed to judge the effect of physiotherapy in Parkinsons disease. The placebo therapy arm should try to compensate for placebo and Hawthorn effects by this group being treated for a similar period of time and in a similar environment as the therapy group. However it is recognised that double-blinding is impossible in therapy trials and so some placebo effect will not be controlled for. After this several large RCTs are needed to demonstrate the most effective form of physiotherapy in Parkinsons disease. In these studies, a rigorous method of randomisation should be used and allocation
12
adequately concealed. Data should be analysed according to intention-to-treat principles. These trials should be carried out and reported according to the guidelines set out in the CONSORT statement (CONSORT 1996). This review emphasises many methodological shortcomings in the trials comparing two forms of physiotherapy in Parkinsons patients. The issues arising from this review have a signicant bearing on the conduct of future physiotherapy trials in Parkinsons disease and other conditions: Firm diagnostic criteria should be used (e.g. UK Parkinsons Disease Brain Bank Criteria, Gibb 1988).
The patients should be followed for at least 6 months after treatment to assess any long term effects of the physiotherapy intervention.
Regardless of the scale used, trials should report whether scores on impairment and disability refer to the on or off phase.
The effect of therapy on drug requirements both in the short and long term should be reported.
Inclusion and exclusion criteria should be clear and trials should aim to enrol uniform cohorts of Parkinson disease patients.
Investigators should clarify at what stage of the disease physiotherapy is being evaluated.
Suitable, clinimetrically sound, outcome measures should be chosen so that the efcacy and effectiveness of physiotherapy can be assessed and an economic analysis performed. Outcomes which have meaning to patients should be used wherever possible since they need to know the value of physiotherapy in practical terms.
Investigators should dene a primary outcome and limit the number of other outcomes measured so as to reduce the possibility of nding false positive results.
The data must be analysed on an intention-to-treat basis and the change in an outcome measure must be compared statistically across the two therapy groups.
Trials must have sufcient numbers of patients to avoid false negative results.
ACKNOWLEDGEMENTS
Many thanks to all of the authors of the included studies who assisted in providing unpublished data and clarication of their methods. Also thanks to all of the people contacted whilst trying to locate any other unpublished randomised controlled trials.
Trials must include clear descriptions of the therapeutic interventions.
REFERENCES
References to studies included in this review

Hirsch 96 {published and unpublished data} Hirsch, M.A. Activity dependent enhancement of balance following strength and balance training. PhD Thesis, Florida State University 1996. [: UMI Number: 9622856] Homann 98 {published and unpublished data} Homann, C.N, R. Crevenna, H. Kojnig, B. Kurzl, S. Reinprecht, K. Wenzel, K. Suppan, G. Ivanic, S. Horner, E. Ott. Can physiotherapy improve axial symptoms in parkinsonian patients? A pilot study with the computerized movement analysis battery Zebris. Movement Disorders 1998;13(Supplement 2):234. Marchese 2000 {published and unpublished data} Abbruzzese, G, M. Diverio, F. Zucchi, R. Marchese. Comparison
of two physical therapy approaches in the rehabilitation of parkinsonian patients. Parkinsonism and Related Disorders 1999;5 (Supplement):S49. Marchese R, M. Diverio, F. Zucchi, C. Lentino, G. Abbruzzese. Comparison of two physical therapy approaches in the rehabilitation of parkinsonian patients: a comparison of two physical therapy protocols. Movement Disorders 2000;15(5): 879883. Mohr 96 {published data only} Mohr, B, V. Muller, R. Mattes, R. Rosin, B. Federmann, U. Strehl, F. Pulvermuller, F. Muller, W. Lutzenberger, N. Birbaumer. Behavioural treatment of Parkinsons disease leads to improvement of motor skills and to tremor reduction. Behaviour Therapy 1996;
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27:235255. Muller, V, B. Mohr, R. Rosin, F. Pulvermuller, F. Muller, N. Birbaumer. Short-term effects of behavioural treatment on movement initiation and postural control in Parkinsons disease: A controlled clinical study. Movement Disorders 1997;12(3):306314. [MEDLINE: 97303399] Palmer 86 {published data only} Palmer, S.S, J.A. Mortimer, D.D. Webster, R. Bistevins, G.L. Dickinson. Comparison of stretch exercises and karate training as therapy for Parkinsons disease. Archives of Physical and Medical Rehabilitaion 1984;65:626. Palmer, S.S, J.A. Mortimer, D.D. Webster, R. Bistevins, G.L. Dickinson. Exercise therapy for Parkinsons disease. Archives of Physical and Medical Rehabilitation 1986;67:741745. Shiba 99 {published data only} Shiba, Y, S. Obuchi, H. Toshima, H. Yamakita. Comparison between visual and auditory stimulation in gait training of patients with idiopathic Parkinsons disease. World Congress of Physical Therapy Conference. 1999. Thaut 96 {published data only} Thaut, M.H, G.C. McIntosh, R.R. Rice, R.A. Miller, J. Rathbun, J.M. Brault. Rhythmic auditory stimulation in gait training for Parkinsons disease patients. Movement Disorders 1996;11(2): 193200. [MEDLINE: 96236298]
CONSORT 1996 Begg, C, M. Cho, S. Eastwood, R. Horton, D. Moher, I. Olkin, R. Pitkin, D. Rennie, K. F. Schultz, D. Simel, D. F. Stroup. Improving the quality of reporting of randomized controlled trials. The CONSORT statement. Journal of the American Medical Association 1996;276(8):637639. Deane Deane K. H. O, D. Jones, C. E. Clarke, E. D. Playford, Y. BenShlomo. Physiotherapy for patients with Parkinsons disease. The Cochrane Library. Gibb 1988 Gibb W. R. G, A. J. Lees. The relevance of the Lewy body to the pathogenesis of idiopathic Parkinsons disease. Journal of Neurology, Neurosurgery and Psychiatry 1988;51:745752. GPDS 2000 The Global Parkinsons Disease Survey. An insight into quality of life with Parkinsons disease. The Parkinsons Disease Society of the United Kingdom 2000. Hildick-Smith 1987 Hildick-Smith M. Has rehabilitation a role in the treatment of Parkinsons disease?. In: Clifford-Rose F editor(s). Parkinsons Disease. Clinical and Experimental Advances. Vol. 6, London: Libbey, 1987. Karlsen 1999 Karlsen K H, Larsen J P, Tandberg E, Maeland J G. Inuence of clinical and demographic variables on quality of life in patients with Parkinsons disease. Journal of Neurology, Neurosurgery and Psychiatry 1999;66(4):431435. Lloyd 1999 Lloyd M. The new community care for people for people with Parkinsons disease and their carers. In: Percival R, P. Hobson editor (s). Parkinsons Disease: Studies in Psychological and Social Care. London: BPS Books, 1999:1359. Mutch 1986 Mutch WJ, Strudwick A, Roy SK, Downie AW. Parkinsons disease: disability, review, and management. British Medical Journal 1986; 293:675677. [MEDLINE: 87001239] OReilly 1996 OReilly F, F. Finnan, S. Allwright, G. Davey Smith, Y. BenShlomo. The effects of caring for a spouse with Parkinsons disease on social, psychological and physical well-being. British Journal of General Practice 1996;46:507512. Oxtoby 1982 Oxtoby M. Parkinsons disease patients and their social needs. Parkinsons Disease Society 1982. Pinter 1992 Pinter M. M, R. J. Helscher, Ch. O. J. Nasel, E. Reidl, G. Schnaberth. Quantication of motor decit in Parkinsons disease with a motor performance test series. Journal of Neral Transmission 1992;4:131141. Plant 1999 Plant RP, Jones D, Ashburn A, Lovgreen B, Kinnear E, Handford F. Evaluation of physiotherapy in Parkinsons disease - project update. The science and practise of multidisciplinary care in Parkinsons disease and Parkinsonism. London: British Geriatric Society, 1999.
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References to studies excluded from this review

Dam 96 {published data only} Dam M, P. Tonin, S. Casson, F. Bracco, L. Piron, G. Pizzolato, L. Battistin Dam. M, P. Tonin, et al. (1996). Effects of conventional and sensory-enhanced physiotherapy on disability of Parkinsons disease patients. Advances in Neurology 69: 551-555. Dam, M, P. Tonin, et al. (1996). Effects of conventional and sensory-enhanced physiotherapy on disability of Parkinsons disease patients. Advances in Neurology 69: 551-555. Effects of conventional and sensory-enhanced physiotherapy on disability of Parkinsons disease patients. Advances in Neurology 1996;69:551555.
References to ongoing studies

Stallibrass {published data only} Stallibrass, C. Controlled trial to evaluate the effects of lessons in the Alexander Technique on the management of disability by people with Parkinsons disease. National Research Register End Date: 01/03/2001. Wagenaar {published data only} Wagenaar, R. C, R. E. A. van Emmerik, E. E. H. van Wegen, C. J. Th. de Goede, G. Tissingh, T. W. Koelman. Exercising dynamics of walking in Parkinsons disease. 13th International World Congress of Physical Therapy. 1999:PLRR-018-25J.
Additional references
Clarke 1995 Clarke CE, Zobkiw RM, Gullaksen E. Quality of life and care in Parkinsons disease. British Journal of Clinical Practice 1995;49(6): 288293. [MEDLINE: 96151530]
Popham 1973 Popham, W. J, K. A. Sirotnik. Nonparametric statistics. EDucational Statistics: Use and Interpretation. 2nd Edition. New York: Harper & Row Publishers, 1973:267282. [: ISDN: 060452528] Tanner 1996 Tanner C. M, J. P. Hubble, P. Chan. Epidemiology and genetics of Parkinsons disease. In: Watts R. L, W. C. Koller editor(s). Movement Disorders. Neurologic Principles and Practise. New York: McGraw Hill, 1996:137160. [: ISBN: 0070352038] Yarrow 1999 Yarrow S. Members 1998 survey of the Parkinsons Disease Society of the United Kingdom. In: Percival R, Hobson P editor(s). Parkinsons disease: Studies in psychological and social care. Leicester: BPS Books, 1999:7992. Indicates the major publication for the study
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Hirsch 96 Methods Parallel group design. Randomised according to a computer generated random number list but concealment of allocation not stated. Analysed on a per protocol basis. Treated as outpatients for an unspecied period of time (3 days/week) for 10 weeks. Assessed at baseline, immediately after treatment and 4 weeks later. Assessors were not blinded. 8 patients in novel combined balance and strength training group and 9 patients in balance training group. 3 drop-outs in combined group. Patients mean age 75.6 (combined), 72.3 (balance); Male/female 5/3 (combined), 6/3 (balance); Hoehn and Yahr 2.0 (total). Inclusion criteria: Parkinsons disease, Hoehn and Yahr stage I-III, were deemed by neurologist or GP to be able to follow testing instructions, with 1 or more of following; falls, unsteadiness walking or standing, difculty rising from chair/bed, muscle weakness in legs. Exclusion criteria: Nursing home residents, hospital inpatients. Combined: Group training in strengthening and balance exercises. Resistance exercises used Nautilus leg extension and side-lying leg-exion machines and therabands. Balance training consisting of gentle sternal or dorsal perturbation and leaning movements designed to enhance limit of stability whilst standing on a rm or a compliant surface. Balance: standard group balance therapy as described above. Not stated whether the drug therapy was constant during treatment. ADL Instrumental ADL Groningen activity restriction scale (GARS) Incidence of falls (use of hands or stepping to maintain balance during testing procedure) Leg muscle strength Body sway (measured by Equitest). NB. Randomisation violation; 1 patient who was allocated to the combined therapy group was reassigned to the balance group after 2 weeks of training due to an inguinal hernia making it impossible for him to carry out the strength training.
Participants
Interventions
Outcomes
Notes
Risk of bias Item Allocation concealment? Authors judgement Unclear Description B - Unclear
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Homann 98 Methods Parallel group design. The patients names were put into alphabetical number and then randomised using computer generated random number tables. Data analysed on an intention to treat basis. Treated as outpatients for 14 units over 5 weeks. Assessed at baseline and immediately after treatment. Not stated whether assessors were blinded. 8 patients in Bobath physiotherapy group and 8 in PNF physiotherapy group. No drop-outs were noted. Baseline characteristics only available for all patients in the 3 arms of this trial. Inclusion criteria: IPD according to UK Brain Bank diagnostic criteria. No exclusion criteria. Bobath: Individual Bobath program focusing on proprioceptive skills to improve posture and gait. PNF: PNF- physiotherapy directed at the mobility of the spine. Therapy carried out by physiotherapist. Drugs were stable for duration of therapy. UPDRS Axial symptoms Stride length Stride velocity Stride cadence Abstract and poster only. No numerical data available.
Participants
Interventions
Outcomes
Notes
Risk of bias Item Allocation concealment? Authors judgement No Description C - Inadequate
Marchese 2000 Methods Parallel group design. Randomised according to a pseudo-random number list, concealment of allocation not stated. Analysed on an intention to treat basis. Treated as outpatients for 18 hours over 6 weeks. Assessed at baseline, immediately afterwards and 6 weeks later. Assessors were blinded. 10 patients in novel cued group and 10 in standard physiotherapy group. No drop-outs stated. Patients mean age 66.9 (cued), 65.0 (standard); total male/female ratio 13/7; Hoehn and Yahr 2.3 (cued), 2.4 ( standard). Inclusion criteria: Stable IPD with no clinical uctuations. Non-demented (MMSE>26). No exclusion criteria. Cued: Individual physical rehabilitation program aimed at improving range of movement, trunk rotation, posture and walking, using external sensory cues. Standard: Individual physiotherapy program described above but without the cues. Drug therapy was stable during therapy period. UPDRS, motor, mental and ADL subsections.
17
Participants
Interventions
Outcomes
Marchese 2000
(Continued)
Notes Risk of bias Item Allocation concealment? Mohr 96 Methods Parallel group design. Randomisation method not stated. Type of analysis of data unclear. Treated as outpatients for 30 hours over 10 weeks. Assessed at baseline and immediately after treatment. Assessors were blinded. 20 patients in novel behavioural therapy group and 21 in standard therapy group. 2 patients dropped out of the standard group. Patients mean age 63.6 (behaviour), 60.4 (standard); male/female 15/5 (behaviour) , 12/9 (standard); Hoehn and Yahr 2.0 (behaviour), 2.1 (standard). Inclusion criteria: IPD with no change in medication for 4 weeks prior to study. Exclusion criteria: History of drug or alcohol abuse, depression, dementia or other psychiatric disorders, other signicant illness. Behavioural: Groups of 3-4 patients. Progressive muscle relaxation aimed at reducing tremor, motor training with use of external cues and internal commands, social interactions training using role playing and aiming at reducing stress. Standard: Groups of 5-7 patients. Breathing and physical exercises, short relaxation, given information on disease and discussion of specic disease-related problems with therapists. Therapy carried out by clinical psychologists. Drugs stable during therapy period. UPDRS, motor, mental and ADL subsections. Hoehn and Yahr Swab and England Beck Depression Inventory Motor performance test series Assertiveness questionnaire Contentment with life questionnaire Muller 1997 reports a subsection of the original population. Authors judgement Unclear Description B - Unclear
Participants
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment?
Authors judgement Unclear
Description B - Unclear
18
Palmer 86 Methods Parallel group design. Randomisation method not stated. Analysed on an intention to treat basis. Treated as outpatients for 36 hours over 12 weeks. Assessed at baseline and immediately after treatment. Assessors were blinded. 7 patients in novel karate exercise group and 7 patients in standard stretch exercises group. No drop-outs. Patients mean age 65.9 (karate), 63.9 (standard); 12 males and 2 females total; Hoehn and Yahr stage 2.4 for both groups. Inclusion criteria: stable drug regime, ability to attend. Exclusion criteria: any physical problems that might cause them to risk injury during the exercises. Karate: Group training in upper body karate exercises with patients seated. Led by a rehabilitation nursing student with a black belt in karate. Standard: Group training in stretch exercises from UPF exercise program led by a corrective therapist. Drugs remained constant during therapy. Parkinsons disease motor battery ADL Grip strength Motor coordination and speed
Participants
Interventions
Outcomes
Notes Risk of bias Item Allocation concealment? Shiba 99 Methods Cross-over group design. Method of randomisation not stated. Method of analysis of the data not stated. Treated as outpatients for an unknown period of time. 1 week between each training regime. Assessed at baseline and immediately after treatment. Not stated whether the assessors were blinded. 4 patients in each group. No drop-outs noted. Total patients mean age 65, 3 males, 5 females. Hoehn and Yahr score not given. Inclusion criteria: Stable mild to moderate Parkinsons disease. No exclusion criteria. Group I: Individual visually stimulated gait training followed by auditory stimulated gait training. Group II: Individual auditory training followed by visual training. Visual training: patients walked over parallel lines at 90 degrees to the direction of travel. Distance apart of lines dependant on patients normal stride length. Auditory stimulation: Patients walked to a rhythm that was 30% higher than their comfortable walking rhythm. Both type of sessions stopped upon fatigue. Not stated whether drugs were kept stable. Authors judgement Unclear Description B - Unclear
Participants
Interventions
19
Shiba 99
(Continued)
Outcomes Notes Risk of bias Item Allocation concealment? Thaut 96 Methods
Stride length Abstract only. No numerical data available.
Authors judgement Unclear
Description B - Unclear
Parallel group design. Randomised by a random draw, but the concealment of allocation was unclear. Analysed on an intention to treat basis. Treated at home or in the community, for 10.5 hours over 3 weeks. Assessed in laboratory, at baseline and immediately after treatment. Not stated whether assessors were blinded. 15 patients in novel rhythmic auditory stimulation group (RAS) and 11 in standard self paced training group (SPT). NO drop-outs noted. Patients mean age 69 (RAS), 74 (SPT); male/female 10/5 (RAS), 8/3 (SPT), Hoehn and Yahr 2.4 (RAS), 2.5 (SPT). Inclusion criteria: IPD with signicant gait decits but able to walk without physical assistance. No exclusion criteria. RAS: Individual. 30 min/day walking to 3 different tempos of music. For 1st week; normal tempo = pretest cadence, quick = 5-10% faster, fast = an additional 5-10% faster. After each week each tempo was increased by 5-10% to a maximum pace of 130 steps/min. SPT: Individual. 30 min/day walking at normal, quick and fast speeds. Drugs were kept constant throughout trial. Stride velocity Stride cadence Stride length EMG analysis on leg muscles. 3 arms to trial; RAS, SPT and no treatment. SPT vs. no treatment are compared in Physiotherapy for patients with Parkinsons disease Cochrane review.
Participants
Interventions
Outcomes
Notes
Risk of bias Item Allocation concealment? Authors judgement Unclear Description B - Unclear
20
Characteristics of excluded studies [ordered by study ID]
Dam 96
Patients not randomly allocated to the two therapy groups.
Characteristics of ongoing studies [ordered by study ID]

Stallibrass Trial name or title A controlled trial to evaluate the effect of a course of lessons in the Alexander technique on the management of disability in Parkinsons disease.
Methods Participants 90 patients. Inclusion criteria: Idiopathic Parkinsons disease, diagnosed by a consultant neurologist; a minimum score on a cognitive decit test; able to get into car unaided; willing to make no changes in their Parkinsons drugs for 3 months. Exclusion criteria: Receiving treatment for any other serious disorder affecting the CNS or psychotrophic medication for depression; previous experience of the Alexander Technique; other individual non-pharmacological therapies in the last 3 months. Group A: 24 lessons in the Alexander Technique. Group B: Untreated. Group C: 24 sessions of therapeutic massage. Self report questionnaires: ADL at best times of day. Beck Depression Inventory. Body Concept Scale. Timed measures. Medical questionnaire. Tested at baseline, immediately after and 6 months after intervention. Start date: 01/09/1998 End date: 01/01/2001 Dr C Stallibrass, Flat 18, Manor Mansions, Belsize Park, London, NW3 4NB, UK. stallic@wmin.ac.uk
Interventions
Outcomes
Starting date
Contact information
21
Stallibrass
(Continued)
Notes
www.update-software.com.NRR.htm
Wagenaar Trial name or title Methods Participants 22 Parkinsons disease patients. Eligibility criteria unknown. Pilot study examining the effects of gait training in PD patients. Walking velocity. Other gait parameters. Unknown. Dr Wagenaar. wagenaar@bu.edu Exercising dynamics of walking in Parkinsons disease.
Interventions Outcomes
Starting date Contact information
Notes
22
DATA AND ANALYSES

This review has no analyses.
WHATS NEW
Last assessed as up-to-date: 28 November 2000.
13 November 2008
Amended
Converted to new review format.
HISTORY
Protocol rst published: Issue 4, 2000 Review rst published: Issue 1, 2001
29 November 2000
New citation required and conclusions have changed
Substantive amendment
CONTRIBUTIONS OF AUTHORS
K H O Deane carried out the majority of the searching for eligible studies. All reviewers were involved in the determination of which studies were eligible for the review. K H O Deane and C Ellis-Hill extracted the data from the included studies. All reviewers were involved in the writing of the review. K H O Deane was the primary author.
DECLARATIONS OF INTEREST
None.
SOURCES OF SUPPORT Internal sources

City Hospital NHS Trust, UK.
23
External sources
NHS Research and Development Programme for People with Physical and Complex Disabilities; Project PCD2/A1/250, UK. Conference grant from The Royal Society, UK. Conference grant from Pharmacia Upjohn, UK.
INDEX TERMS Medical Subject Headings (MeSH)

Physical
Therapy Modalities; Parkinson Disease [ rehabilitation]; Randomized Controlled Trials as Topic
MeSH check words

Humans
24

Physiotherapy For Parkinsons

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Physiotherapy for Parkinsons disease: a comparison of techniques (Review)

Deane K, Jones DE, Ellis-Hill C, Clarke CE, Playford ED, Ben-Shlomo Y

Physiotherapy for Parkinsons disease: a comparison of techniques

Criteria for considering studies for this review

Search methods for identication of studies

Data collection and analysis

Table 1. Key Characteristics of Included Studies

Number of Mean Age Patients

Mean Duration Hoehn & Yahr Score

Table 1. Key Characteristics of Included Studies

Strength & None balance Vs balance Bobath PNF Vs None

Marchese 2000 Mohr 96

30 hours/10 Outpatients weeks

36 hours/12 Outpatients weeks Unspecied Outpatients

10.5 hours/3 Home weeks

6 5 Cued trials Outpatients; 1 Home

Risk of bias in included studies

Homann 98 A Marchese 2000 Mohr 96 A

Table 2. Methodological Quality of Included Studies

Palmer 86 Shiba 99 Thaut 96

A A A KEY: A: Adequate B: Unclear (not stated) C: Inadequate

B B C KEY: A: Good B: Unclear (not stated) C: Weak (eg alternate allocation)

B B B KEY: A: Adequate B: Unclear (not stated) C: Inadequate

A B A KEY: A: Good B: Unclear (not stated) C: Poor

A A A KEY: A: Good, <10% B: Unclear (not stated) C: Poor, >10%

A A A KEY: A: Good, <10% B: Unclear (not stated) C: Poor, >10%

A B A KEY: A: Constant B: Unclear (not stated) C: Allowed Variation

A B A KEY: A: Adequate B: Unclear (not stated) C: Inadequate

AUTHORS CONCLUSIONS Implications for practice

Implications for research

Trials must include clear descriptions of the therapeutic interventions.

References to studies included in this review

References to studies excluded from this review

References to ongoing studies

Characteristics of included studies [ordered by study ID]

Risk of bias Item Allocation concealment? Authors judgement No Description C - Inadequate

Notes Risk of bias Item Allocation concealment?

Authors judgement Unclear

Outcomes Notes Risk of bias Item Allocation concealment? Thaut 96 Methods

Stride length Abstract only. No numerical data available.

Authors judgement Unclear

Characteristics of excluded studies [ordered by study ID]

Patients not randomly allocated to the two therapy groups.

Characteristics of ongoing studies [ordered by study ID]

Starting date Contact information

DATA AND ANALYSES

Converted to new review format.

New citation required and conclusions have changed

SOURCES OF SUPPORT Internal sources

INDEX TERMS Medical Subject Headings (MeSH)

Therapy Modalities; Parkinson Disease [ rehabilitation]; Randomized Controlled Trials as Topic

MeSH check words

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