This is not the most recent version of the article. View current version (15 AUG 2012)
Physiotherapy versus placebo or no intervention in Parkinson's disease
Editorial Group: Cochrane Movement Disorders Group
Published Online: 11 JUL 2012
Assessed as up-to-date: 31 DEC 2010
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Tomlinson CL, Patel S, Meek C, Clarke CE, Stowe R, Shah L, Sackley CM, Deane KHO, Herd CP, Wheatley K, Ives N. Physiotherapy versus placebo or no intervention in Parkinson's disease. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD002817. DOI: 10.1002/14651858.CD002817.pub2.
- Publication Status: Edited (conclusions changed)
- Published Online: 11 JUL 2012
This is not the most recent version of the article.View current version (15 Aug 2012)
Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and well-being, thereby enhancing quality of life.
To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.
We identified relevant trials by electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to end of December 2010.
Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD.
Data collection and analysis
Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions.
We identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s, 95% confidence interval (CI): 0.02 to 0.07, P = 0.0002), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson’s Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). There was no difference between arms in falls or patient-rated quality of life. Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.
Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.
The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.
Plain language summary
Physiotherapy for treatment of Parkinson's disease
In spite of various medical and surgical treatments for Parkinson's disease (PD), patients gradually develop significant physical problems. Physiotherapists aim to enable people with PD to maintain their maximum level of mobility, activity and independence through monitoring their condition and targeting the appropriate treatment. A range of approaches to movement rehabilitation are used, which aim to enhance quality of life by maximising physical ability and minimising secondary complications over the whole course of the disease.
Only randomised controlled trials were included in this review. These were studies where a group of participants were given physiotherapy intervention and compared with another group who did not receive physiotherapy. The participants were assigned to a group in a random fashion to reduce the potential for bias. Thirty-three randomised trials involving 1518 participants were identified as suitable for this review. The trials assessed various physiotherapy interventions, so the trials were grouped according to the type of intervention being used (general physiotherapy, exercise, treadmill training, cueing, dance or martial arts).
There was an improvement with physiotherapy intervention in all walking outcomes (except the 10- or 20-metre walk test). However, these improvements were only significant for walking speed, walking endurance and step length. Mobility and balance outcomes were also improved with physiotherapy intervention, with significant improvements in one test of mobility (the Timed Up & Go test which times how long it takes a person to get up from a chair, walk a certain distance, then walk back to the chair and sit down) and in two tests of balance (one assessing how far a person can reach before they lose balance (Functional Reach Test) and another which assesses multiple aspects of balance (Berg Balance Scale)). Clinician-rated disability, using the Unified Parkinson’s Disease Rating Scale (UPDRS), was also improved with physiotherapy intervention. There was no difference between the two groups in data on falls or patient-rated quality of life. When comparing the different physiotherapy interventions, there was no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.
This review provides evidence on the short-term benefit of physiotherapy for the treatment of PD. Although most of the observed differences were small, the improvements seen for walking speed, balance with the Berg Balance Scale and clinician-rated disability (using the UPDRS) were of a size that patients would consider an important improvement.