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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

    This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, 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.

    http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/
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    T A B L E O F C O N T E N T S

    1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    12AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    13ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    13REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    15CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    23SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    24INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

    Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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    [Intervention Review]

    Physiotherapy for Parkinsons disease: a comparison oftechniques

    Katherine Deane2, Diana E Jones3, Caroline Ellis-Hill4, Carl E Clarke1, E Diane Playford5, Yoav Ben-Shlomo6

    1Departmentof Neurology, CityHospital, Sandwell andWestBirminghamHospitals NHSTrust,Birmingham,UK. 2Instituteof Health

    & Society, Newcastle University, Newcastle-upon-Tyne, UK. 3School of Health, Community and Education Studies, Northumbria

    University, Newcastle upon Tyne, UK. 4Health and Rehabilitation Research Unit, University of Southampton, Southampton, UK.5Directorate of Musculoskeletal and Rehabilitational Services, The National Hospital for Neurology and Neurosurgery, London, UK.6Dept 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. [email protected].

    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-ShlomoY. Physiotherapy for Parkinsons disease: a comparison

    of techniques. Cochrane Database of Systematic Reviews2001, Issue 1. Art. No.: CD002815. DOI: 10.1002/14651858.CD002815.

    Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    A B S T R A C T

    Background

    Despite optimal medical and surgical therapies for Parkinsons disease, patients develop progressive disability. The role of the physio-

    therapist 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 comparethe efficacy andeffectiveness of novel physiotherapy techniquesversus standard physiotherapy in patientswith Parkinsons

    disease. Standard physiotherapy is defined as the type of therapy that the physiotherapist would usually use to treat Parkinsons disease.

    2. To compare the efficacy and effectiveness of one physiotherapy technique versus a second form of physiotherapy.

    Search strategy

    Relevant trials were identified 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 l isting service, the metaRegister

    of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR; and examination of the reference lists of identified 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.

    1Physiotherapy for Parkinsons disease: a comparison of techniques (Review)

    Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    mailto:[email protected]:[email protected]
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    Main results

    Seven trials were identified 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 flaws in many of the studies and the possibility of publication

    bias, there is insufficient evidence to support or refute the efficacy of any given form of physiotherapy over another in Parkinsons

    disease. Another Cochrane review, Physiotherapy for patients with Parkinsons Disease, found that there was insufficient evidence to

    support or refute the efficacy 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 confirmed 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 efficacy of standard physiotherapy should be proved first 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).

    P L A I N L A N G U A G E S U M M A R Y

    In spite of the best medical and surgical treatments for Parkinsons disease, patients develop significant 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 benefits of one form of physiotherapy versus another for people with Parkinsons disease. Relevant trials

    were identified by electronic searches of 21 medical literature databases, various registers of clinical trials and an examination of the

    reference lists of the identified 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 flaws in many of the studies, there is insufficient evidence to support

    the use of one form of physiotherapy over another for the treatment of Parkinsons disease.

    Another Cochrane review that examined the efficacy of physiotherapy versus placebo (sham) therapy (Physiotherapy for patients with

    Parkinsons Disease) concluded that there was insufficient evidence to support or refute the efficacy of physiotherapy in Parkinsons

    disease.

    The benefits of standard physiotherapy should be proved first 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.

    2Physiotherapy for Parkinsons disease: a comparison of techniques (Review)

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    B A C K G R O U N D

    The modern management of Parkinsons disease centres on phar-

    macological 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 fluctuations in response. In spite of

    optimal pharmacological therapy, the underlying disease contin-

    ues to progress. All existing treatments provide only symptomatic

    benefit 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. Significant

    disability can occur in the early stages of the disease with patients

    becoming dependent for washing, dressing, eating and other ac-

    tivities of daily living. The severity of these disabilities usually in-

    creases 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 Parkin-

    sons disease is to maximise functional ability and minimise sec-

    ondary complications through movement rehabilitation within a

    context of education andsupport forthe whole person. This work-

    ing definition of physiotherapy for Parkinsons disease has been

    generated from the results of an evaluation of best practice phys-

    iotherapy 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 withthe Parkinsons Disease Society in 1982 found that 29% had seen

    a physiotherapist (Oxtoby 1982). In Mutch et als 1986 commu-

    nity-based study of 267 patients, only 7% had seen a physiother-

    apist (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 physio-

    therapy services, perception of lack of benefit and difficulties withinterpretation of trials due to flawed methodology.

    This review of randomised clinical trials aims to compare the ef-

    ficacy and effectiveness of novel physiotherapy techniques versus

    standard physiotherapy in patients with Parkinsons disease. It will

    also compare the efficacy and effectiveness of one novel physio-

    therapy technique versus a second novel form of physiotherapy.

    Another Cochrane review assesses the effect of active physiother-

    apy compared with placebo (Deane).

    O B J E C T I V E S

    To compare the efficacy and effectiveness of novelphysiotherapy techniques versus standard physiotherapy in

    patients with Parkinsons disease.

    To compare the efficacy and effectiveness of one

    physiotherapy technique versus a second form of physiotherapy.

    M E T H O D S

    Criteria for considering studies for this review

    Types of studies

    All randomised controlled trials comparing two types of physio-

    therapy 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 defined

    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. Handicapand quality of lifemeasures, bothdisease specific,(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.

    3Physiotherapy for Parkinsons disease: a comparison of techniques (Review)

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    Search methods for identification of studies

    1. The review is based on the search strategy of the Movement

    Disorders Group and also the following more general search strat-

    egy:

    a. Physiotherapy OR physical therapy OR exercise OR rehabilita-

    tion

    b. Parkinson OR Parkinsons disease OR Parkinsonism

    c. #a AND #b

    Relevant trials were identified by electronic searches of general

    biomedical and science databases: MEDLINE (1966-2000), EM-

    BASE (1974-2000), CINAHL (1982-2000), ISI-SCI ((1981-

    2000); rehabilitation databases: AMED (1985-2000), MAN-

    TIS (1880-2000), REHABDATA (1956-2000), REHADAT,

    GEROLIT (1979-2000); English language databases of foreign

    language research and third world publications: Pascal (1984-

    2000), LILACS (1982-2000), MedCarib (17th Century-2000),

    JICST-EPlus (1985-2000), AIM (1993-2000), IMEMR (1984-

    2000) 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 Tri-

    als, 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 inter-nal reports) were searched. This included The XIII Interna-

    tional Congress on Parkinsons disease (1999), The International

    Congress of Parkinsons Disease and Movement Disorders (1990,

    92,94, 96,97, 98), TheAmerican Academy of Neurology 51st an-

    nual 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 AslibIn-

    dex 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 andcolleges that carry out degreecourses in physio-

    therapy were asked to searchfor anyrelevant 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 identified by the

    search strategy. Disagreements about inclusions were resolved by

    discussion. The full papers were assessed for methodological qual-

    ity 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 formsindependently, checked for accuracy and amal-

    gamated. Disagreements about inclusions were resolved by discus-

    sion.

    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

    andpartIIImotor.Althoughwerecognisethatthisiscontroversial,

    Popham 1973 reported that when parametric procedures have

    been employed with ordinal data, they rarely distort a relationship

    betweenvariables 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 froma series of dichotomous questions (which are weighted equally),

    there is no equality of interval and so this data was analysed in a

    nonparametric fashion.

    R E S U L T S

    Description of studies

    See: Characteristics of includedstudies; 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

    Patients

    Mean Age Mean

    Hoehn &

    Yahr Score

    Duration Location Type of

    Physio.

    Additional

    therapy?

    Individual or

    Group?

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    unequally size groups (3-4 patients in novel groups versus 5-7 pa-

    tients 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

    qualifications were. It was unclear in the remaining three trials (

    Marchese 2000, Homann 98, Shiba 99 ) what the qualifications

    were of those conducting the therapy.

    Five of the trials used visual or auditory cues to promote move-

    ment in the patients, however the amount of emphasis placed onthe cueing and the method of physiotherapy against which it was

    compared varied significantly. Overall the methods of physiother-

    apy varied so significantly 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 phys-

    iotherapy 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

    Marchese 2000 carried out an individual physical rehabilitation

    program including visual and auditory cues and compared thesepatients to another group that underwent a similar movement

    rehabilitation program but without the cues.

    Mohr 96

    Mohr 96s novel group underwent behavioural therapy that in-

    cluded relaxation techniques, role playing and motor training us-

    ing external cues (visual and auditory). These patients were com-

    pared with a standard group that were given breathing and physi-

    cal exercises (without cues), short relaxation and discussion of dis-

    ease-related problems. The two methods were described as being

    distinct from one another.

    Palmer 86Palmer 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 hada cross-over design. GroupI hadvisually stim-

    ulated gait training followed by auditory stimulated gait training.

    Group II had auditory stimulated gait training first. There was

    one week between each training regime.

    Thaut 96

    Thaut 96 gave auditory stimulated gait training using three differ-

    ent 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.

    Table 2. Methodological Quality of Included Studies

    Study Specified El-igibility Cri-

    teria

    Randomisa-tion Method

    Conceal-ment of Al-

    location

    Similarity atBaseline

    With-drawals De-

    scribed

    Missing Val-ues

    Cointerven-tions Con-

    stant (e.g.

    drugs)

    Blinded as-sessors

    Hirsch 96 A A B A C C B C

    Homann 98 A A A B A A A B

    Marchese

    2000

    A A B A A A A A

    Mohr 96 A B B A A A A A

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    Table 2. Methodological Quality of Included Studies (Continued)

    Palmer 86 A B B A A A A A

    Shiba 99 A B B B A A B B

    Thaut 96 A C B A A A A A

    KEY: A:

    Adequate B:

    Unclear (not

    stated) C:

    Inadequate

    KEY:

    A: Good B:

    Unclear (not

    stated) C:

    Weak (eg al-

    ternate allo-

    cation)

    KEY: A:

    Adequate B:

    Unclear (not

    stated) C:

    Inadequate

    KEY:

    A: Good B:

    Unclear (not

    stated) C:

    Poor

    KEY: A:

    Good,

    10%

    KEY: A:

    Good,

    10%

    KEY: A:

    Constant B:

    Unclear (not

    stated)

    C: Allowed

    Variation

    KEY: A:

    Adequate B:

    Unclear (not

    stated) C:

    Inadequate

    METHOD OF RANDOMISATION AND CONCEAL-

    MENT 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 usedcomputer 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 variedconsiderably 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 rep-

    resentative 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 specified were

    female (33%), this could introduce difficulty when trying to ap-

    ply 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 im-

    portant to decide whether the results are generalizable andto com-pare characteristics of the two groups to ensure that the randomi-

    sation 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 betweenthe therapy groups. The gender

    of the patients in each therapygroup wasonly statedin 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 five 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

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    The methods of physiotherapy used were generally described only

    in a very broad manner. It would have been useful if a fuller de-scription of the method of therapy had been given so that it would

    be easier to compare these trial with others. However further de-

    tails of the exact protocol used was available from Thaut 96 on

    request. In particular the time spent with the therapist was not

    specifiedin 3 of6 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 ther-

    apy 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 thanthose 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,

    thisismoreareflectionofthefactthatthesefourtrialshadnodrop-outs and therefore by default the data is analysed on an intention-

    to-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 whenone of the patients

    randomised to the novel (combined therapy) group developed an

    inguinal hernia2 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 ofShiba99. If it had been data from the first arm of the trial would be

    required so as to remove the possibility of carry-over effects.

    OnlyThaut 96 specified a primary outcome (walking velocity on

    flat and inclined surfaces). Examining multiple outcomes carries

    the risk of multiple analyses and a higher risk of finding spurious

    but statistically significant 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 therapyA vs change due to therapy B). The remain-

    ing 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 thananother, 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 efficacy 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 detectionbiasis unlikely inthese three studies.

    Thaut 96 used a computerised gait analysis system and so detection

    bias is unlikely in this study. However theassessors 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 identified comparing two formsof physiotherapy

    with 142 patients in total. There was significant 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 thetrial. The authors

    of the other studies provided the mean andSD at baseline andafter

    treatment for each therapy group. We are awaiting advice from

    the Cochrane Collaboration and other statistical departments ona 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 condi-

    tions. Falls were defined 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 fixed or sway-reference

    surface, with eyes shut, eyes open, or eyes open and the surround-

    ings also sway-referenced. Both methods decreased the number of

    falls, but statistical analysis was not given. Those patients receiv-

    ing 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 significant difference (P

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    Unsurprisingly, those patients receiving combined strength andbalance training significantly increased the strength of their leg

    muscles as compared to the balance traininggroup (P

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    D I S C U S S I O N

    PRINCIPAL FINDINGS

    Seven randomised controlled trials were found comparing

    two forms of physiotherapy (142 patients). These studies varied

    significantly 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 significantly better than another.

    Considering the small number of patients examined, the

    methodological flaws in the studies, and the possibility ofpublication bias, it is unsafe to draw any conclusions regarding

    the efficacy 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 efficacy 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 tri-

    als, e.g. proprioceptive neuromuscularfacilitation,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 high-

    lights 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 reportingwas 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 trials used insufficient numbers of patients to avoid drawing

    false negative conclusions and to reduce the possibility of selectionbias. It is now generally accepted that quality of life measures

    should be used as the primary outcome of interest in clinical trials.

    Onlyone trial (Mohr 96) used QOL scales, and as only 41 patients

    were examined in this study there is insufficient 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

    numbertablesandarandomdrawinonestudy( Thaut 96).There-

    maining threetrials did not statehow randomisation was achieved.

    Inall seven trialsthe concealment of theallocation wasinadequate,

    unclear or not stated.

    It is vital that eligibility criteria are well defined so that it is un-derstood 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 reducethe

    likelihood of including patients with Parkinsons plus syndrome

    which have a significantly different clinical course compared to

    idiopathic Parkinsons disease. The eligibility criteria should also

    define 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 specified in fourtrials. Also the intensity of the therapy was never defined in any of

    the studies examined. This means that it would be hard to repro-

    duce the studies methodology. It is recognised that physiother-

    apy 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 specified were female.

    This is in contrast to the general population of Parkinsons pa-

    tients were the prevalence of the disease is equal between the sexes

    (Tanner 1996). This is a common finding in Parkinsons disease

    trials but raises the question of whether the results are generalis-

    able to the whole Parkinsons disease population and to women inparticular.

    OUTCOME MEASURES

    The outcome measures used varied greatly between the trials. The

    outcome measures used in fiveof theseven trialswere only assessed

    at baseline and immediately after therapy. It would have beenvalu-

    able to know the long-term duration of any improvement follow-

    ing therapy. The outcome measures used must be clinimetrically

    sound and reliably reflect the impact of physiotherapy on the pa-

    tients life.

    Motor Impairment: Global Scales:

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    The motor subsection (part III) of the UPDRS is one of the most

    popular rating scale used in clinical trials in recent years. The UP-DRS-Motor subsection combines disability and handicap mea-

    sures in thesamescale.Thisscale was used in both Marchese 2000

    and Mohr 96. Marchese 2000 found that the cued therapy was

    not significantly better than uncued physiotherapy immediately

    after the therapyregime. However when thepatientswere followed

    for a further six weeks the cued therapy group differed from the

    uncued group by 4.9 points (Mann Whitney p

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    These tests of ADL can be said to be more an assessment of motor

    functionas they representan artificialsituation, e.g. patientswouldrarely 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.

    Quality of Life

    Mohr 96 used a Contentment of Lifescore to assess general QOL

    and health related QOL. We have no knowledge of its validity, re-

    liability 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 significance of a

    0.17 point difference for general contentment of life and a 0.02

    point difference for health-related contentment. The clinical sig-

    nificance 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 dur-

    ing the therapy sessions and also in the practice at home. The

    therapy itself might affectdepression. The patients mood may im-

    prove 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 con-

    founders. 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 significant proportion of the reduction in quality of life due

    to Parkinsons disease.

    The Beck Depression Index (BDI) is a highly validated and sen-

    sitive score to assess depression that has been used in a number of

    studies of Parkinsons disease patients. The BDI is a 21 item, self-

    rated 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 per-

    formed. There was a difference of 0.63 points between the groups

    in favour of standard therapy but the clinical significance of sucha small difference is doubtful.

    UPDRSmental subsection wasusedto measure mood in Marchese

    2000 and Mohr 96. This subsection consists of only four ques-

    tions 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 be-

    tween the two therapy groups in onlyMarchese 2000. The small

    difference seen in Marchese 2000 (0.5 points) is not statistically

    significant. Mohr 96 detected a difference of 0.13 points. It is

    probable that neither difference is clinically significant.

    Carer Outcomes

    Approximately 75% of patients with Parkinsons disease l ive with

    a partner, who is usually of a similar age and may have disabilitiesof 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 per-

    formed which precludes an understanding of the economic value

    of this therapy.

    A U T H O R S C O N C L U S I O N S

    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 firm 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 methodologi-

    cal flaws in many of the studies, there is insufficient evidence to

    support the use of one form of physiotherapy over another for thetreatment of Parkinsons disease.

    Another Cochrane review that examined the efficacy of physio-

    therapy versus placebo or no therapy (Physiotherapy for patients

    with Parkinsons Disease) concluded that there was insufficient ev-

    idence to support or refutethe efficacy of physiotherapy in Parkin-

    sons disease. Although a recent survey (Plant 1999) has deter-

    mined 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 defined in sufficient detail so as to allow the

    examination of the efficacy of physiotherapy in Parkinsons disease

    in a large multi-centre trial.

    The efficacy of standard physiotherapy mustbe proved firstbefore

    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

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    adequately concealed. Data should be analysed according to in-

    tention-to-treat principles. These trials should be carried out andreported 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 significant

    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).

    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.

    Investigators should define a primary outcome and limit

    the number of other outcomes measured so as to reduce the

    possibility of finding false positive results.

    Trials must have sufficient numbers of patients to avoid

    false negative results.

    Trials must include clear descriptions of the therapeutic

    interventions.

    The patients should be followed for at least 6 months aftertreatment 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.

    Suitable, clinimetrically sound, outcome measures should

    be chosen so that the efficacy 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.

    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.

    A C K N O W L E D G E M E N T S

    Many thanks to all of the authors of the included studies who

    assisted in providing unpublished data and clarification of their

    methods. Also thanks to all of the people contacted whilst trying

    to locate any other unpublished randomised controlled trials.

    R E F E R E N C E S

    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 Disorders1998;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 ofparkinsonian patients. Parkinsonism and Related Disorders1999;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 Disorders2000;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 Therapy1996;

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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 Disorders1997;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 Disorders1996;11(2):

    193200. [MEDLINE: 96236298]

    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 EndDate: 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 Practice1995;49(6):

    288293. [MEDLINE: 96151530]

    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. Ben-

    Shlomo. 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 Psychiatry1988;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. Influence of

    clinical and demographic variables on quality of life in patients with

    Parkinsons disease. Journal of Neurology, Neurosurgery and

    Psychiatry1999;66(4):431435.

    Lloyd 1999Lloyd 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 Journal1986;

    293:675677. [MEDLINE: 87001239]

    OReilly 1996

    OReilly F, F. Finnan, S. Allwright, G. Davey Smith, Y. Ben-

    Shlomo. The effects of caring for a spouse with Parkinsons disease

    on social, psychological and physical well-being. British Journal of

    General Practice1996;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. Quantification of motor deficit 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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    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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    C H A R A C T E R I S T I C S O F S T U D I E S

    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 unspecified period of time (3 days/week) for 10 weeks.

    Assessed at baseline, immediately after treatment and 4 weeks later. Assessors were not blinded.

    Participants 8 patients innovel 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,

    difficulty rising from chair/bed, muscle weakness in legs.

    Exclusion criteria: Nursing home residents, hospital inpatients.

    Interventions Combined: Group training in strengthening and balance exercises. Resistance exercises used Nautilus leg

    extension and side-lying leg-flexion 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 firm or a compliant surface.

    Balance: standard group balance therapy as described above.

    Not stated whether the drug therapy was constant during treatment.

    Outcomes 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).

    Notes 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.

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear 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.

    Participants 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.

    Interventions 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.

    Outcomes UPDRS

    Axial symptoms

    Stride length

    Stride velocity

    Stride cadence

    Notes Abstract and poster only.

    No numerical data available.

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? No 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.

    Participants 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 fluctuations. Non-demented (MMSE>26). No exclusion

    criteria.

    Interventions 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.

    Outcomes UPDRS, motor, mental and ADL subsections.

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    Marchese 2000 (Continued)

    Notes

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear B - Unclear

    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.

    Participants 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 significant illness.

    Interventions 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 specific disease-related problems with therapists. Therapy carried out by clinical

    psychologists.

    Drugs stable during therapy period.

    Outcomes 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

    Notes Muller 1997 reports a subsection of the original population.

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear B - Unclear

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    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.

    Participants 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.

    Interventions 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.

    Outcomes Parkinsons disease motor battery

    ADL

    Grip strength

    Motor coordination and speed

    Notes

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear B - Unclear

    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.

    Participants 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.

    Interventions 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.

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    Shiba 99 (Continued)

    Outcomes Stride length

    Notes Abstract only. No numerical data available.

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear B - Unclear

    Thaut 96

    Methods 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.

    Participants 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 significant gait deficits but able to walk without physical assistance. No

    exclusion criteria.

    Interventions 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.

    Outcomes Stride velocity

    Stride cadence

    Stride length

    EMG analysis on leg muscles.

    Notes 3 arms to trial; RAS, SPT and no treatment. SPT vs. no treatment are compared in Physiotherapy forpatients with Parkinsons disease Cochrane review.

    Risk of bias

    Item Authors judgement Description

    Allocation concealment? Unclear B - Unclear

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    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 deficit 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-pharmaco-

    logical therapies in the last 3 months.

    Interventions Group A: 24 lessons in the Alexander Technique.

    Group B: Untreated.

    Group C: 24 sessions of therapeutic massage.

    Outcomes 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.

    Starting date Start date: 01/09/1998

    End date: 01/01/2001

    Contact information Dr C Stallibrass,

    Flat 18, Manor Mansions,

    Belsize Park,

    London,

    NW3 4NB,

    UK.

    [email protected]

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    Stallibrass (Continued)

    Notes www.update-software.com.NRR.htm

    Wagenaar

    Trial name or title Exercising dynamics of walking in Parkinsons disease.

    Methods

    Participants 22 Parkinsons disease patients.

    Eligibility criteria unknown.

    Interventions Pilot study examining the effects of gait training in PD patients.

    Outcomes Walking velocity.

    Other gait parameters.

    Starting date Unknown.

    Contact information Dr Wagenaar.

    [email protected]

    Notes

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    D A T A A N D A N A L Y S E S

    This review has no analyses.

    W H A T S N E W

    Last assessed as up-to-date: 28 November 2000.

    13 November 2008 Amended Converted to new review format.

    H I S T O R Y

    Protocol first published: Issue 4, 2000

    Review first published: Issue 1, 2001

    29 November 2000 New citation required and conclusions have changed Substantive amendment

    C O N T R I B U T I O N S O F A U T H O R S

    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.

    D E C L A R A T I O N S O F I N T E R E S T

    None.

    S O U R C E S O F S U P P O R T

    Internal sources

    City Hospital NHS Trust, UK.

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    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.

    I N D E X T E R M S

    Medical Subject Headings (MeSH)

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

    MeSH check words

    Humans

    24Physiotherapy for Parkinsons disease: a comparison of techniques (Review)

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