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Intervenciones para Enfermedad de Parkinson

Physical Therapy Interventions for Parkinson
Robyn Gisbert and Margaret Schenkman
PHYS THER. Published online November 25, 2014
doi: 10.2522/ptj.20130334
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Running Head: Physical Therapy Interventions for Parkinson Disease
<LEAP> Linking Evidence And Practice
Physical Therapy Interventions for Parkinson Disease
Robyn Gisbert, Margaret Schenkman
R. Gisbert, PT, DPT, Physical Therapy Program, School of Medicine, University of
Colorado, 13121 E 17th Ave, Mail Stop C244, Aurora, CO 80045 (USA). Address all
correspondence to Dr Gisbert at: [email protected].
M. Schenkman, PT, PhD, FAPTA, Physical Therapy Program, University of Colorado
Health Sciences Center, Denver, Colorado.
[Gisbert R, Schenkman M. Physical therapy interventions for Parkinson disease. Phys
Ther. 2015;95:xxx–xxx].
©2014 American Physical Therapy Association
Publish ahead of print xxxx
Accepted: November 13, 2014
Submitted: July 19, 2013
Dr Schenkman provided concept/idea/research design. Both authors provided writing.
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<LEAP> highlights the findings and application of Cochrane reviews and other evidence
pertinent to the practice of physical therapy. The Cochrane Library is a respected source
of reliable evidence related to health care. Cochrane systematic reviews explore the
evidence for and against the effectiveness of appropriate interventions – medications,
surgery, education, nutrition, exercise – and the evidence for and against the use of
diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the
decisions of clinicians, patients, and others in health care by providing a careful review
and interpretation of research studies published in the scientific literature. Each article in
this PTJ series summarizes a Cochrane review or other scientific evidence on a single
topic and presents clinical scenarios based on real patients or programs to illustrate how
the results of the review can be used to directly inform clinical decisions. This article
focuses on an adult patient with relatively early Parkinson’s disease. Can physiotherapy
intervention strategies improve his physical functioning, and help him to reach his goal
of engaging in an exercise program to prevent decline related to progressive PD.
Background /Introduction
Parkinson’s disease (PD) is a multifaceted neurodegenerative disorder affecting
both motor and non-motor function. 1,2,3 PD is considered a disorder of the basal ganglia,
because of its effect on the transmission of signals from the basal ganglia (BG) to the
thalamus for roles in voluntary movement (including initiation, execution, and
termination), cognition, and emotion. One of the major consequences of PD is
degeneration of the substantia nigra of the midbrain which is the trigger for the abnormal
signaling from the BG. The cardinal signs are tremor, rigidity, bradykinesia, and postural
instability. Other motor symptoms include difficulty with motor planning and dual task
performance.3 In addition, this disorder leads to a wide range of non-motor symptoms that
could potentially affect the individual’s quality of life and also his or her participation in
Approximately 1% of Americans over the age of 60, and an estimated 4% of the
oldest Americans, are now diagnosed with PD. This prevalence is anticipated to double
by 2030. 4 The mean age of initial diagnosis is around 60, 5 although a type of young
onset PD can occur and diagnosis also can occur in late life. In most cases, there is no
known cause of the disorder (i.e., it is idiopathic). People with PD often are categorized
by Hoehn and Yahr (H&Y) stages (from 1-5) with Stage 1 indicating only minor
symptoms and Stage 5 indicating the person is completely disabled and typically is
confined to a bed. 6 Presentation of symptoms varies among individuals. Although there is
a spectrum of presentation, two specific subtypes of have been identified with distinct
clinical features and with different implications for prognosis. Specifically, PD is
differentiated into two forms: tremor-predominant and postural instability and gait
difficulty (PIGD). 7,8
The mainstay of intervention for people with PD of all stages is medical
management including pharmacological options in early stages and surgical options (e.g.,
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deep brain stimulation, DBS) in later stages.1 Common pharmaceutical approaches
include dopamine replacement, dopamine agonists, inhibitors of dopamine metabolism,
and anticholinergic agents. In the past 15 years, a number of investigations have
demonstrated positive outcomes from physical rehabilitation for people in early and midstages of PD. 9,10,11 Some of the intervention approaches are framed around improvements
of direct consequences of PD (e.g., difficulty with dual task performance), others focus
on sequelae (e.g., strength, flexibility, aerobic conditioning), and some are more global,
addressing a variety of underlying impairments.6,12,13
Over the past decade, a number of reviews and systematic reviews have
consistently suggested physical intervention is beneficial for people with PD.9,10,11,12
However, most of the reviewed studies were relatively small, and not of strong
methodological quality.
Given the burgeoning number and increasing quality of more recent studies,
Tomlinson et al conducted a systematic review of the literature up to December 2010,
published in the Cochrane Database of Systematic Reviews, 2012. 14 This review was
conducted as a follow up to the Cochrane review published in 2001 and only included
trials that compared physiotherapy interventions to either placebo or no intervention. A
total of 33 trials were selected for review with 37 comparisons. Of these 33 trials, 29
compared physiotherapy intervention to no intervention and 4 to placebo intervention. A
total of 1518 participants were included. They were of any duration of PD, any age, any
drug therapy and any duration of physical therapy treatment. The trials were categorized
as follows: general physical therapy (5), exercise (12), treadmill (7), cueing (7), dance
(2), and martial arts (4). The number of treatment hours varied widely across studies (4.5
to 72), as did the number of weeks (2 to 52). Information was not provided regarding
whether home programs were included in the protocols. Not all interventions were
delivered by a physiotherapist. Tomlinson et al14 concluded that the risk of bias of
included trials has improved since the 2001 Cochrane review; however improvement still
is needed in both implementation and reporting. For example, the size of the studies is
larger (about 50 participants compared with 25 in 2001). However, only 7/33 studies used
the United Kingdom Brain Bank Criteria, which is the standard for diagnosing PD.
Assessors were blinded in only 64% of the studies, and compliance was reported in only
a third of the studies. Follow-up was short-term (usually about 3 months). A large
number of outcome measures were used across these studies, including self-report and
performance-based measures. Many of the measures related to balance, gait, and falls,
although measures also were included of overall symptoms, quality of life, and disability.
Of the measures included in the studies, there was sufficient data for a meta-analysis of
18 outcomes.
Take-Home Message
Based on their review, the authors concluded that significant short-term benefits
are obtained with physiotherapy intervention on the following outcome measures: Twoand six-minute walk tests, walking velocity, step length, Timed Up and Go test (TUG),
Functional Reach (FR) test, Berg Balance Scale (BBS), and Unified Parkinson’s Disease
Rating Scale, UPDRS (Total, ADL, and Motor scores) (Tab. 1). Of these only the
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improvements seen for walking velocity, BBS, and UPDRS scores were judged to be at
levels of clinical importance. Post-intervention between group differences were small but
judged by the review authors to be clinically meaningful. The authors compared
improvements obtained by different intervention approaches and concluded they were
small, supporting the notion that any of the interventions can lead to relatively
comparable outcomes on these key measures. However, they cautioned that these were
indirect comparisons; direct comparisons between intervention approaches are needed.
Improvements also were demonstrated for other walking outcomes such as
cadence and stride length. However these differences were not judged to be clinically
meaningful. Nor was there a significant difference between the data from those receiving
physiotherapy interventions and those in the control groups for falls or patient-rated
quality of life.
Case # XX: Applying evidence to a patient with early stage Parkinson’s disease
Can physical therapy intervention help this patient?
Mr. Jennings, a 54 year-old financial planner currently in H&Y Stage 2, was
diagnosed with PD four years ago. His symptoms began seven years ago with weakness
and tremor on his left side. He had not received prior physical therapy for PD.
Medications and supplements included: pramipexole, selegiline and amantadine, CoQ10,
a multivitamin and omega 3 fish oil. He had no significant comorbid conditions. His
goal was to engage in a therapeutic exercise program to prevent decline related to PD.
Mr. Jennings denied falls but reported feeling stiff, moving slowly, and being concerned
about balance and walking, particularly in crowded environments.
The physical therapy evaluation included measures of function and assessment of
underlying impairments that could limit current or future abilities with balance and gait.
A number of these measures were reported in the Cochrane Review including the Timed
Up and Go, Functional Reach, and six- minute walk tests. Additional measures of
balance and gait included the Five Times Sit to Stand test (FTSST) and the Functional
Gait Assessment (FGA). 15 His score of 25/30 on the FGA indicated a mild fall risk. He
was able to ascend and descend a full flight of stairs without use of a railing, indicating
good lower extremity strength. This was further confirmed by his ability to perform the
FTSST in 10 seconds and without use of hands. On clinical examination, cardinal signs
of PD were evident, including resting tremor observable in his left hand, bradykinesia
(limbs and whole body movements), and mild rigidity (limbs and trunk) that increased
when he performed a cognitive dual task during passive range of motion. Mr. Jennings’
sitting posture was characterized by a posterior pelvic tilt and he stood with mild thoracic
kyphosis. Both postures were somewhat flexible, suggesting potential for remediation.
Functional Axial Rotation (FAR) was measured. This test quantifies the combined
movements of multiple spinal regions, when a seated subject turns as far as possible
without unweighting the pelvis. FAR was asymmetric and limited to 103° right and 97°
left. This contrasts with data from 18 men ages 40-59 for whom FAR (mean, SD) was
117.9° (14.2) (Schenkman, unpublished). Lastly, Mr. Jennings had a PDQ-39
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Questionnaire summary index score of 5.1, indicating mild impact of PD on his quality of
life. 16
How did the physical therapist apply the results of the Cochrane Review to Mr.
Mr. Jennings’ physical therapist posed the following question: Will a physical
therapy program (compared with no treatment) improve physical functioning of a 54 year
old man with Hoehn and Yahr Stage 2 of PD? Findings from the Cochrane systematic
review completed by Tomlinson and colleagues were applied using the PICO (Patient,
Intervention, Comparison, Outcome) approach as follows:
Patient. The review included people with PD who were in H&Y stages of 1-4
(mean stage of 2.4), mean age of 67, and six years post diagnosis. Mr. Jennings was in
Stage 2, was younger than the mean (age 54), and had been diagnosed for four years.
Thus Mr. Jennings fit into the overall criteria, but was younger and had the diagnosis for
less time than the mean of the people in the studies reported.
Intervention. The studies reported in the review included interventions
categorized as general physical therapy, exercise, treadmill, cueing, dance, and martial
arts (Tab. 1). The strategies chosen for Mr. Jennings, based on his individual
impairments and his goal of preventing decline associated with aging and PD, were most
similar to those categorized as general physical therapy and exercise. Specifically, his
intervention included progressive resistive exercises (PREs), aerobic conditioning,
balance reeducation and flexibility training using the axial mobility program. 17 In
contrast to most of the studies, much of his plan of care was implemented with a home
exercise program. With regard to dose, Mr. Jennings was seen for six physical therapy
sessions (45-60 minutes each) over eight weeks, consistent with the lowest doses reported.
To encourage adherence to home exercise, the patient and therapist stayed in contact
through email. The patient submitted exercise logs, asked questions, and received
feedback and encouragement.
Comparison and alternate approaches. The review compared physical therapy
intervention strategies to placebo control or no intervention. Mr. Jennings had not been
exercising. Based on the review, it appeared that a variety of physical therapy
approaches could benefit Mr. Jennings. Decisions regarding which specific elements to
include among the various intervention possibilities were determined by Mr. Jennings’
specific underlying impairments coupled with his preferences. For Mr. Jennings, it was
deemed important to improve his axial mobility. He had limitations in FAR and reported
stiffness as a concern. Furthermore, one of his goals was to prevent declines in flexibility
and function while aging with PD. Thus axial mobility was a significant component of
his exercise program. Mr. Jennings was offered dance as an option for treatment,
however he was not interested. He had home exercise equipment (i.e., treadmill and
weight machines) and expressed a desire to learn how to exercise with his home gym
equipment. It is difficult to make direct comparisons to the studies reviewed, as they
varied widely, both in terms of dose and timing of the interventions.
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Outcomes. The review concluded that all interventions, including the general
physiotherapy interventions and exercise trials, demonstrated small, short-term beneficial
changes for people with PD for gait, balance, and/or functional mobility measures.
Some of the outcome measures used with Mr. Jennings were consistent with those
reported in the review.
How well do the outcomes of the intervention provided to
Mr. Jennings match those suggested by the systematic review?
The interventions provided for Mr. Jennings were most similar to those in the
general physiotherapy and exercise trials. Tomlinson et al. reported significant
improvements in FR with data from the exercise and cuing groups and in the TUG with
data from the exercise, cuing, dance and martial arts groups. This participant’s
improvements in balance, as evidenced by the FR and TUG tests, were at the high end of
the changes reported by Tomlinson et al.
Only limited data are available for the MCID of measures in PD and
predominantly are from one study to date. The data reported may be from much more
impaired individuals as the changes noted (e.g., 9 cm in forward FR, 11 sec for TUG) and
would be improbable for Mr. Jennings, given his baseline status. Mr. Jennings’ six
minute walk change score met the criteria of 50 m as the MCID reported for a variety of
individuals with a variety of cardiopulmonary diagnoses. 18
Insert Table 2 about here.
Three outcomes were chosen that were not included in the review: FAR, FTSST
and FGA. FAR was considered important, given this patient’s limited axial mobility
compared with age comparable individuals and given the known relationship between
FAR and balance. 19 FTSST was chosen because of its ability to predict fall risk and as a
proxy for lower extremity strength. FGA was used rather than the BBS. The latter would
have been too easy for this patient and the FGA includes tasks such as walking
backwards, head turns while walking, and ambulating on stairs, all of which were
particularly relevant for this individual.
Change in FAR was not reported in the systematic review, however it is
noteworthy that the change in FAR (20°) was at the high end of improvement reported by
Schenkman et al. 20 No comparison data were found for the other two outcomes.
Can you apply the results of the systematic review to your own patients?
Based on the PICO analysis, the results of the Cochrane review can be applied to
patients such as Mr. Jennings. Clinicians should, however, consider a number of
limitations to the data. First, the outcomes related to gait and balance but not to overall
ability to function. This is important because improvements of gait do not necessarily
lead to improvements in basic activities of daily living such as dressing and hygiene and
to overall household activities such as cooking, cleaning, and managing laundry. Second,
only short-term outcomes were examined. Yet PD is a progressive condition, hence shortterm benefits are important, but may be of true benefit only if the patient develops the
skills and strategies for long-term adherence to appropriate exercise and activity.22 In this
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regard, data are needed regarding the best strategies to assist patients to develop
appropriate activity and long-term exercise habits.
Additional limitations include: 1) no evidence was provided regarding specificity
of intervention approaches; 2) evidence was insufficient to determine the most
appropriate dose (intensity, frequency); 3) physiotherapy interventions were compared to
no intervention or to placebo control ; 4) constraints of third-party payers may preclude a
sufficient number of supervised sessions, hence consideration should be given to a
combination of supervised and home programs to achieve the desired goals, although
data are lacking regarding safety and the optimal balance between supervised and home
components of a combined intervention.
Further, evidence is not yet available to determine the best intervention strategies,
based on subgroups of the disease (tremor predominate from PIGD form) or H&Y stages
of PD. And finally, many patients have substantial co-morbid conditions that should be
taken into account when designing the plan of care, both because of safety implications
and because they can contribute to deficits of movement and function.
Lastly, it is worth noting that across studies within the review, a high number of
outcomes were used, and that these varied between studies. This is indicative of the lack
of consistency that investigators are using to identify the impact of PD on health, function
and quality of life.
What can be advised based on the results of this systematic review?
Findings from this systematic review demonstrate that people with PD achieve
greater short-term improvements in gait and balance with physiotherapy intervention than
do those individuals who receive placebo control or no physiotherapy intervention.
Because PD is a progressive condition, short-term benefits are important, but may be of
true benefit only if the patient develops the skills and strategies for long-term adherence
to appropriate exercise and activity.25 Furthermore, these findings were obtained with a
range of intervention approaches including general physical intervention, exercise, cueing,
treadmill training, dance and martial arts. Hence clinicians can consider any of a range of
intervention approaches when working with people, especially in early and mid-stages of
PD and can take into account patient preferences. This finding is important given that
people with PD likely need to develop long-term exercise habits to sustain benefits.
Individuals are most likely to adhere to an exercise regimen if they are doing something
they enjoy. Furthermore, some individuals may be more likely to develop sustained
exercise habits if they can vary their approach. At the same time, clinicians are cautioned
to consider the impairments that are most limiting to their patients when recommending
which intervention approaches to use.
Several large scale randomized controlled trials (RCTs) were published since this
Cochrane review, comparing interventions to one another. 21,22,23,24 These studies
illustrate specificity of training. For example, aerobic training improves cardiovascular
function; resistance training improves muscle strength. This is important to consider,
given that patients’ problems are multi-faceted and there is no single presentation of PD
across patients. Additionally, considerable recent attention focuses on the possibility that
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exercise of sufficient intensity may be neuroprotective, 25 suggesting that intensity may be
critical. Lastly, attention also has turned to the importance of overall physical activity in
addition to prescribed exercise for managing health of people with PD. 26
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Table 1. Key results from the 2012 Cochrane review
The review included 33 randomized, controlled trials with a total of 1518 participants; H&Y 2.4 ; the number of participants in each
trial ranged from 6-153. Search included trials published up to the end of December 2010.
Risk of Bias: Of the reported upon criteria1 for risk of bias in the studies 44% were low, 46% unclear and 10% high. The most
frequent areas of high risk were in randomization and withdrawals.
 General physical therapy (5 trials; 5 compared to no intervention, 0 to placebo control)
 Participants: n=197; mean age 65; 70% male; H&Y 2.3; 4 years since diagnosis
 Intervention: Approach: movement strategies, exercise, hands on treatment, education and advice for gait, balance
transfers, posture and fitness; Duration: 5 weeks to 12 months; Session length not provided
 Exercise (12 trials; 10 compared to no intervention, 2 to placebo control)
 Participants: n=635; mean age 67; 63% male; H&Y 2.4; 6 years since diagnosis
 Intervention: Approach: strength, balance, walking, falls prevention, neuromuscular facilitation, resistance and aerobic
training, education, and relaxation; Duration: 3-24 weeks; Session length: 30 min to 2 hrs
 Treadmill (7 trials; 5 compared to no intervention, 2 to placebo control)
 Participants: n =179; mean age 67; 68% male; H&Y 2.4; 5 years since diagnosis
 Intervention: Approach: walking on treadmill with adjustment of speed and incline; Duration: 4-8 weeks; Session
length: 30-60 min
 Cueing (7 trials; 7 compared to no intervention, 0 to placebo control)
 Participants: n=303; mean age 68; 60% male; H&Y 2.5; 7 years since diagnosis
 Intervention: Approach: audio, visual, and sensory feedback (six applied to gait; one applied to sit to stand transfer);
Duration: 2-8 weeks; Session length: 20 min to 2 hrs.
 Dance (2 trials; 2 compared to no intervention, 0 to placebo control)
 Participants: n=635; mean age 69; 64% male; H&Y 2.3; 7 years since diagnosis
 Intervention: Approach: Trained instructor for tango, waltz, or foxtrot; Duration: 12-13 weeks; Session length of 1 hr
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 Martial arts (4 trials; 4 compared to no intervention, 0 to placebo control)
 Participants: n=143; mean age 66; 72% male; H&Y 2.1; 7 years since diagnosis
 Intervention: Approach: Tai Chi (3); Quigong (1); Duration: 12-24 weeks; Session length: 1 hr
A number of outcomes were reported in the various studies. Of those that were included, the following showed significant
improvements with physiotherapy intervention as compared to placebo control or no intervention:
Gait outcomes
 Two or six minute walk: mean difference = 16.4 m; 95% CI 1.90 to 30.90
Approach: exercise, dance , martial arts ; Trials= 4; Participants: n=172
 Ten or 20 m-walk: mean difference = .40 sec; 95% CI 0.00 to 0.80
Approach: exercise, treadmill; Trials= 4; Participants: n=169
 Velocity: mean difference = 0.05 m/sec; 95% CI 0.02 to 0.07
Approach: general physiotherapy, exercise, treadmill, cuing, dance , martial arts ; Trials= 11; Participants: n=529
 Step length: mean difference = 3 cm; 95% CI 0.00 to 0.06
Approach: general physiotherapy ,exercise, treadmill, cuing; Trials= 3; Participants: n=239
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Clinician-rated disability Unified Parkinson’s Disease Rating Scale (UPDRS)
 Total; mean difference = -4.46 points; 95% CI -7.16 to – 1.75
Approach: general physiotherapy, treadmill; Trials= 2; Participants: n=105
 ADL: mean difference = -1.36 points; 95% CI -2.41 to -0.30
Approach: general physiotherapy, treadmill, dance; Trials= 4; Participants: n=157
 Motor: mean difference = -4.09 points; 95% CI -5.59 to -2.59
Approach: general physiotherapy, exercise, treadmill, cuing, dance , martial arts ; Trials= 9; Participants: n=431
The following outcomes did not show any difference with physiotherapy intervention as compared to placebo control or no
Gait outcomes
 Cadence (steps/min) : mean difference = -1.72 steps/min; CI -4.01 to 0.58
Approach: general physiotherapy , exercise, treadmill, cuing; Trials= 6; Participants: n=327
 Stride length (m) : mean difference = 0.03 m; CI -2.78 to 7.57
Approach: general physiotherapy ,exercise, treadmill, cuing, dance, martial arts; Trials= 5; Participants: n=202
 Freezing of Gait Questionnaire : mean difference = -1.19; CI -0.02 to 0.09
Approach: exercise , cuing, dance ; Trials= 3; Participants: n=246
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Functional Mobility and Balance Outcomes
 Activity of Balance Scale : mean difference = 2.4 points; CI -2.78 to 7.57
Approach: general physiotherapy , cuing; Trials= 3; Participants: n=66
 Falls Efficacy Scale: mean difference = 2.4 points; CI 4.76 to 0.94
Approach: exercise , cuing; Trials= 4; Participants: n=353
Patient-rated quality of Life
 Parkinson’s Disease Questionarre-39( PDQ-39) : mean difference =-0.35 points; CI -2.66 to 1.96
Approach: general physiotherapy, exercise, dance, cuing, martial arts; Trials= 6; Participants: n=387
No trial reported data on adverse events
Not every study reported on every criterion.
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Table 2. Outcomes from the intervention for Mr. Jennings
Outcome measure
Functional Reach Test
35.56 cm
Discharge (8 weeks)
38.10 cm
2.54 cm
Timed Up and Go Test
Six Minute Walk Test
Five Times Sit to Stand Test
Functional Axial Rotation (degrees)
Functional Gait Assessment (30 total)
10 sec
500 m
10 sec
8 sec
650 m
10 sec
-2.0 sec
150 m
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Physical Therapy Interventions for Parkinson
Robyn Gisbert and Margaret Schenkman
PHYS THER. Published online November 25, 2014
doi: 10.2522/ptj.20130334
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