Physiotherapy for Parkinson's disease: a comparison of techniques
Abstract
Background
Despite optimal medical and surgical therapies for Parkinson's disease, patients develop progressive disability. The role of the physiotherapist is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. What form of physiotherapy is most effective in the treatment of Parkinson's disease remains unclear.
Objectives
1. To compare the efficacy and effectiveness of novel physiotherapy techniques versus 'standard' physiotherapy in patients with Parkinson's disease. Standard physiotherapy is defined as the type of therapy that the physiotherapist would usually use to treat Parkinson's disease.
2. To compare the efficacy and effectiveness of one physiotherapy technique versus a second form of physiotherapy.
Search methods
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 listing 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.
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 Parkinson's disease. Another Cochrane review, Physiotherapy for patients with Parkinson's Disease, found that there was insufficient evidence to support or refute the efficacy of physiotherapy compared to no physiotherapy in Parkinson's 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 Parkinson's disease (Plant 1999). Therefore a consensus must be found as to 'best practice' physiotherapy for Parkinson's 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 Parkinson's disease. After this large RCTs are needed to demonstrate the most effective form of physiotherapy in Parkinson's 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).
PICOs
Plain language summary
In spite of the best medical and surgical treatments for Parkinson's disease, patients develop significant physical problems. Physiotherapists aim to enable people with Parkinson's 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 Parkinson's 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 Parkinson's disease.
Another Cochrane review that examined the efficacy of physiotherapy versus placebo (sham) therapy (Physiotherapy for patients with Parkinson's Disease) concluded that there was insufficient evidence to support or refute the efficacy of physiotherapy in Parkinson's 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 Parkinson's disease. After this, large RCTs are needed to demonstrate the most effective form of physiotherapy in Parkinson's 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.
