Physiotherapy in Parkinson's Disease: A Meta-Analysis of Present Treatment Modalities.

BACKGROUND: Physiotherapy is a commonly prescribed intervention for people with Parkinson's disease (PD). Conventional types of physiotherapy have been studied extensively, while novel modalities are being developed and evaluated. OBJECTIVE: To evaluate the effectiveness of conventional and more recent physiotherapy interventions for people with PD. The meta-analysis performed as part of the 2014 European Physiotherapy Guideline for PD was used as the starting point and updated with the latest evidence. METHODS: We performed a systematic search in PubMed, CINAHL, Embase, and Web of Science. Randomized controlled trials comparing any physiotherapy intervention with no intervention or sham treatment were included. Trials were classified into 12 categories: conventional physiotherapy, resistance training, treadmill training, strategy training, dance, martial arts, aerobic exercises, hydrotherapy, balance and gait training, dual tasking, exergaming, and Nordic walking. Outcomes included motor symptoms, balance, gait, and quality of life, and are presented as standardized mean differences. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to systematically appraise methodological quality. RESULTS: A total of 191 trials with 7998 participants were included. Conventional physiotherapy significantly improved motor symptoms, gait, and quality of life. Resistance training improved gait. Treadmill training improved gait. Strategy training improved balance and gait. Dance, Nordic walking, balance and gait training, and martial arts improved motor symptoms, balance, and gait. Exergaming improved balance and quality of life. Hydrotherapy improved balance. Finally, dual task training did not significantly improve any of the outcomes studied. CONCLUSIONS: This meta-analysis provides a comprehensive overview of the evidence for the effectiveness of different physiotherapy interventions in the management of PD, allowing clinicians and patients to make an evidence-based decision for specific treatment modalities. Further work is needed to directly compare the relative efficacy of the various treatments.

The European Physiotherapy Guideline for Parkinson's Disease: Implications for Neurologists.

The evidence for physiotherapy is growing, showing a positive impact on functional activities involving gait, transfers and balance. Specific recommendations for physiotherapists, physicians and people with Parkinson's disease were published in the European Physiotherapy Guideline for Parkinson's disease. Here, we summarize the referral criteria, highlight the importance of accurate referral to specialized physiotherapists, and emphasize the potential benefits of expert care. As such, this paper offers very practical guidance for clinicians working with Parkinson's disease patients and who consider physiotherapy treatments for their patients.

Training dual tasks together or apart in Parkinson's disease: Results from the DUALITY trial.

BACKGROUND AND OBJECTIVES: Many controversies surround the usefulness of dual-task training in Parkinson's disease (PD). This study (1) compared the efficacy of two different dual-task training programs for improving dual-task gait and (2) assessed the possible fall risk of such training. METHODS: Patients (N = 121) with a diagnosis of PD (aged 65.93 [±9.22] years, Hoehn and Yahr stage II-III on-medication) were randomized to (1) a consecutive group in which gait and cognitive tasks were trained separately or (2) an integrated group in which gait and cognitive tasks were trained simultaneously. Both interventions involved 6 weeks of at-home physiotherapist-led training. Two baseline tests were performed as a 6-week control period before training. Posttests were performed immediately after training and at 12-week follow-up. Dual-task gait was assessed during trained and untrained secondary tasks to assess consolidation of learning. Fall risk was determined by a weekly telephone call for 24 weeks. RESULTS: No significant time by group interactions were found, suggesting that both training modes had a similar effect on dual-task gait. Immediately after training, and not after the control period, significant improvements (P < .001) in dual-task gait velocity were found in all trained and untrained dual tasks. Improvements ranged between 7.75% and 13.44% when compared with baseline values and were retained at 12-week follow-up. No significant change in fall risk occurred in both study arms (P = .84). CONCLUSIONS: Consecutive and integrated dual-task training led to similar and sustained improvements in dual-task gait velocity without increasing fall risk. These novel findings support adoption of dual-task training in clinical practice. © 2017 International Parkinson and Movement Disorder Society.

Test-Retest Reliability of Dual-Task Outcome Measures in People With Parkinson Disease.

BACKGROUND: Dual-task (DT) training is gaining ground as a physical therapy intervention in people with Parkinson disease (PD). Future studies evaluating the effect of such interventions need reliable outcome measures. To date, the test-retest reliability of DT measures in patients with PD remains largely unknown. OBJECTIVE: The purpose of this study was to assess the reliability of DT outcome measures in patients with PD. DESIGN: A repeated-measures design was used. METHODS: Patients with PD ("on" medication, Mini-Mental State Examination score ≥24) performed 2 cognitive tasks (ie, backward digit span task and auditory Stroop task) and 1 functional task (ie, mobile phone task) in combination with walking. Tasks were assessed at 2 time points (same hour) with an interval of 6 weeks. Test-retest reliability was assessed for gait while performing each secondary task (DT gait) for both cognitive tasks while walking (DT cognitive) and for the functional task while walking (DT functional). RESULTS: Sixty-two patients with PD (age=39-89 years, Hoehn and Yahr stages II-III) were included in the study. Intraclass correlation coefficients (ICCs) showed excellent reliability for DT gait measures, ranging between .86 and .95 when combined with the digit span task, between .86 and .95 when combined with the auditory Stroop task, and between .72 and .90 when combined with the mobile phone task. The standard error of measurements for DT gait speed varied between 0.06 and 0.08 m/s, leading to minimal detectable changes between 0.16 and 0.22 m/s. With regard to DT cognitive measures, reaction times showed good-to-excellent reliability (digit span task: ICC=.75; auditory Stroop task: ICC=.82). LIMITATIONS: The results cannot be generalized to patients with advanced disease or to other DT measures. CONCLUSIONS: In people with PD, DT measures proved to be reliable for use in clinical studies and look promising for use in clinical practice to assess improvements after DT training. Large effects, however, are needed to obtain meaningful effect sizes.

Are factors related to dual-task performance in people with Parkinson's disease dependent on the type of dual task?

BACKGROUND: Impaired dual-task performance significantly impacts upon functional mobility in people with Parkinson's disease (PD). The aim of this study was to identify determinants of dual-task performance in people with PD in three different dual tasks to assess their possible task-dependency. METHODS: We recruited 121 home-dwelling patients with PD (mean age 65.93 years; mean disease duration 8.67 years) whom we subjected to regular walking (control condition) and to three dual-task conditions: walking combined with a backwards Digit Span task, an auditory Stroop task and a Mobile Phone task. We measured dual-task gait velocity using the GAITRite mat and dual-task reaction times and errors on the concurrent tasks as outcomes. Motor, cognitive and descriptive variables which correlated to dual-task performance (p < 0.20) were entered into a stepwise forward multiple linear regression model. RESULTS: Single-task gait velocity and executive function, tested by the alternating intake test, was significantly associated with gait velocity during the Digit Span (R(2) = 0.65; p < 0.001), the Stroop (R(2) = 0.73; p < 0.001) and the Mobile Phone task (R(2) = 0.62; p < 0.001). In addition, disease severity proved correlated to gait velocity during the Stroop task. Age was a surplus determinant of gait velocity while using a mobile phone. CONCLUSION: Single-task gait velocity and executive function as measured by a verbal fluency switching task were independent determinants of dual-task gait performance in people with PD. In contrast to expectation, these factors were the same across different tasks, supporting the robustness of the findings. Future study needs to determine whether these factors predict dual-task abnormalities prospectively.

Dual tasking in Parkinson's disease: should we train hazardous behavior?

Dual-task (DT) circumstances aggravate gait disorders in Parkinson's disease (PD) and are associated with an increased risk of falling and reduced functional mobility. Clinical rehabilitation guidelines for PD consider DT interventions as potentially hazardous and recommend avoiding them in daily life. The current article challenges this notion and addresses the necessity of implementing DT training in PD. First, underlying reasons for DT interference in PD and current theoretical models are discussed. Subsequently, different training approaches to tackle DT difficulties are put forward. Finally, the effectiveness and limitations of DT training in PD are reviewed. We conclude that there is a need for DT interventions in PD and recommend randomized, power-based studies to further test their efficacy.

Protocol for a randomized comparison of integrated versus consecutive dual task practice in Parkinson's disease: the DUALITY trial.

BACKGROUND: Multiple tasking is an integral part of daily mobility. Patients with Parkinson's disease have dual tasking difficulties due to their combined motor and cognitive deficits. Two contrasting physiotherapy interventions have been proposed to alleviate dual tasking difficulties: either to discourage simultaneous execution of dual tasks (consecutive training); or to practice their concurrent use (integrated training). It is currently unclear which of these training methods should be adopted to achieve safe and consolidated dual task performance in daily life. Therefore, the proposed randomized controlled trial will compare the effects of integrated versus consecutive training of dual tasking (tested by combining walking with cognitive exercises). METHODS AND DESIGN: Hundred and twenty patients with Parkinson's disease will be recruited to participate in this multi-centered, single blind, randomized controlled trial. Patients in Hoehn & Yahr stage II-III, with or without freezing of gait, and who report dual task difficulties will be included. All patients will undergo a six-week control period without intervention after which they will be randomized to integrated or consecutive task practice. Training will consist of standardized walking and cognitive exercises delivered at home four times a week during six weeks. Treatment is guided by a physiotherapist twice a week and consists of two sessions of self-practice using an MP3 player. Blinded testers will assess patients before and after the control period, after the intervention period and after a 12-week follow-up period. The primary outcome measure is dual task gait velocity, i.e. walking combined with a novel untrained cognitive task to evaluate the consolidation of learning. Secondary outcomes include several single and dual task gait and cognitive measures, functional outcomes and a quality of life scale. Falling will be recorded as a possible adverse event using a weekly phone call for the entire study period. DISCUSSION: This randomized study will evaluate the effectiveness and safety of integrated versus consecutive task training in patients with Parkinson's disease. The study will also highlight whether dual task gait training leads to robust motor learning effects, and whether these can be retained and carried-over to untrained dual tasks and functional mobility. TRIAL REGISTRATION: Clinicaltrials.gov NCT01375413.

The effectiveness of allied health care in patients with ataxia: a systematic review.

Many patients with cerebellar ataxia have serious disabilities in daily life, while pharmacological treatment options are absent. Therefore, allied health care is considered to be important in the management of these patients. The goal of this review is to evaluate scientific evidence for allied health care in cerebellar ataxia, to identify effective treatment strategies, and to give recommendations for clinical practice and further research. A systematic search for clinical trials concerning allied health care in cerebellar ataxias was conducted using the electronic databases of PubMed, Medline, Embase, Cinahl and Pedro, and references lists of articles, in the time period from 1980 up to and including December 2011 in English and Dutch. We identified 14 trials, of which the four best studies were formally of moderate methodological quality. There was a wide variation in disease entities and interventions. The combined data indicate that physical therapy may lead to an improvement of ataxia symptoms and daily life functions in patients with degenerative cerebellar ataxia (level 2), and in other diseases causing cerebellar ataxia (level 3). When added to physical therapy, occupational therapy might improve global functional status, and occupational therapy alone may diminish symptoms of depression (level 3). There are insufficient data for speech and language therapy. Despite the widespread use of allied health care interventions in cerebellar ataxia, there is a lack of good quality studies that have evaluated such interventions. We found some support for the implementation of physical therapy and occupational therapy, but more research is needed to develop recommendations for clinical practice.

Physiotherapy in degenerative cerebellar ataxias: utilisation, patient satisfaction, and professional expertise.

Physiotherapy plays an important role in the management of patients with degenerative cerebellar ataxias. However, our insight in the quantity and quality of physiotherapy prescription in this group of patients is incomplete. The purposes of this study were to investigate the utilization of physiotherapy and patient satisfaction in patients with degenerative ataxias in The Netherlands and to examine the level of expertise and needs of physiotherapists treating ataxia patients. Questionnaires were sent to members of the Dutch association for patients with degenerative cerebellar ataxias (n = 532). In addition, 181 questionnaires were sent to the physiotherapists who had recently treated the patients who responded. Eventually, 317 questionnaires from patients (60 %) and 114 questionnaires from physiotherapists (63 %) could be used for further analysis. Sixty-four percent of the patients were currently treated by a physiotherapist. Their median treatment duration was 5 years. Nineteen percent of the patients had never been referred, often despite the presence of limitations in daily activities. On the other hand, some participants without reported limitations had received physiotherapy. In general, participants were satisfied with their physiotherapist. The most reported treatment goals were improvement or maintenance of balance, general physical condition, and mobility. Physiotherapists reported lack of ataxia-specific expertise and expressed the need for education and evidence-based guidelines. Referral to and use of physiotherapy in patients with degenerative cerebellar ataxia in The Netherlands are currently inconsistent and not in agreement with the little scientific evidence available. Referral rates are high, but referrals and actual necessity are discrepant; treatment duration is long; and ataxia-specific expertise among physiotherapists is insufficient. Evidence-based recommendations and specific training of physiotherapists are needed.

The ParkinsonNet concept: development, implementation and initial experience.

The quality and efficiency of allied health care in Parkinson's disease (PD) must be improved. We have developed the ParkinsonNet concept: a professional regional network within the catchment area of hospitals. ParkinsonNet aims to: (1) improve PD-specific expertise among allied health personnel, by training a selected number of therapists according to evidence-based guidelines; (2) enhance the accuracy of referrals by neurologists; (3) boost patient volumes per therapist, by stimulating preferred referral to ParkinsonNet therapists; and (4) stimulate collaboration between therapists, neurologists, and patients. We describe the procedures for developing a ParkinsonNet network. Our initial experience with this new concept is promising, showing an increase in PD-specific and a steady rise in the patient volume of individual therapists.

The ParkinsonNet trial: design and baseline characteristics.

The companion paper describes how implementation of professional networks (ParkinsonNet) may improve the quality and efficiency of allied health care in Parkinson's disease (PD). We designed a cluster-randomized controlled trial to evaluate this ParkinsonNet concept for one allied health discipline, namely physical therapy. Here we describe the study design and baseline characteristics. The design fully complies with the CONSORT criteria. Sixteen regions in the Netherlands were randomly divided into eight experimental regions where a ParkinsonNet was implemented, and eight control regions where the organization of care was left unchanged (usual care). Participating patients were followed for 6 months to evaluate the implementation process, health benefits and costs of the intervention. In the ParkinsonNet regions, 46 therapists were trained and 358 patients were included. In the usual care regions, 341 patients were included. Baseline characteristics of participants in the ParkinsonNet and control clusters were comparable. With 699 participating patients, this is the largest allied health study in PD to date.

Allied health care in Parkinson's disease: referral, consultation, and professional expertise.

There is evidence for the efficacy of allied health care in Parkinson's disease (PD). However, barriers exist that hamper implementation of evidence into daily practice. We conducted a survey to investigate: (1) to what extent PD patients currently utilize allied health care for relevant problems in the core areas of allied health care and (2) the level of PD-specific expertise among allied health professionals. Questionnaires were sent to 260 patients and 297 allied health professionals. Referral rates were 63% for physical therapy, 9% for occupational therapy, and 14% for speech therapy. PD patients with problems that can potentially be alleviated by input from allied health professionals are often not being referred. Furthermore, most patients were treated by allied health professionals who lacked PD-specific expertise. Current referral to and delivery of allied health care in PD are suboptimal. Evidence-based guidelines for allied health care in PD and active implementation of these guidelines are needed.

Physical therapy in Parkinson's disease: evolution and future challenges.

Even with optimal medical management using drugs or neurosurgery, patients with Parkinson's disease (PD) are faced with progressively increasing mobility problems. For this reason, many patients require additional physical therapy. Here, we review the professional evolution and scientific validation of physical therapy in PD, and highlight several future challenges. To gain insight in ongoing, recently completed or published trials and systematic reviews, we performed a structured literature review and contacted experts in the field of physical therapy in PD. Following publication of the first controlled clinical trial in 1981, the quantity and quality of clinical trials evaluating the efficacy of physical therapy in PD has evolved rapidly. In 2004 the first guideline on physical therapy in PD was published, providing recommendations for evidence-based interventions. Current research is aiming to gather additional evidence to support specific intervention strategies such as the prevention of falls, and to evaluate the implementation of evidence into clinical practice. Although research focused on physical therapy for PD is a relatively young field, high-quality supportive evidence is emerging for specific therapeutic strategies. We provide some recommendations for future research, and discuss innovative strategies to improve the organization of allied health care in PD, making evidence-based care available to all PD patients.

Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research.

Physical therapy is often prescribed in Parkinson's disease. To facilitate the uniformity and efficacy of this intervention, we analyzed current evidence and developed practice recommendations. We carried out an evidence-based literature review. The results were supplemented with clinical expertise and patient values and translated into practice recommendations, developed according to international standards for guideline development. A systematic literature search yielded 6 systematic reviews and 23 randomized controlled trials of moderate methodological quality with sufficient data. Six specific core areas for physical therapy were identified: transfers, posture, reaching and grasping, balance, gait, and physical capacity. We extracted four specific treatment recommendations that were based on evidence from more than two controlled trials: cueing strategies to improve gait; cognitive movement strategies to improve transfers; exercises to improve balance; and training of joint mobility and muscle power to improve physical capacity. These practice recommendations provide a basis for current physical therapy in Parkinson's disease in everyday clinical practice, as well as for future research in this field.

Effectiveness of exercise therapy: a best-evidence summary of systematic reviews.

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Physiotherapy in Parkinson's disease: utilisation and patient satisfaction.

To examine the quality and quantity of physiotherapy care in Parkinson's disease (PD) in the Netherlands, postal questionnaires were sent to 300 PD patients. Patients who had received treatment by a physiotherapist at some stage during the previous year were asked to give approval to contact their therapist. Subsequently, postal questionnaires were sent to 129 physiotherapists who had recently treated the patients that were identified in the first stage of the study. Completed questionnaires were returned by 235 patients and 99 therapists. Sixty percent of patients were currently treated by a physiotherapist, most of them for more than six months. Ninety-five patients had serious problems within at least one of the four core areas of physiotherapy practice in PD (posture, balance, gait, transfers) and were therefore regarded as requiring referral to physiotherapy. Yet, 41% of them received no treatment at the time of enquiry. On the other hand, 75 patients had no serious problems within these core areas, yet half of them currently received treatment. The main goals for treatment were improvement of gait, general physical condition, posture or balance. Treatment mainly comprised active exercises. 60% of patients were treated by therapists without specific interest or education in PD. Most patients were presently satisfied with the treatment, but 11% had previously changed to another therapist because of dissatisfaction. In the Netherlands, referral rates of PD patients to physiotherapy are high and treatment duration is lengthy. Referral seems, to some extent, arbitrary. Scientific evidence for the effectiveness of physiotherapy in PD remains limited.