Standard and Nonstandard Physical Therapy Show Similar Effectiveness for Parkinson Disease

Ramzi G. Salloum, PhD

In a recent systematic review and meta-analysis published in JAMA Network Open, findings showed no significant differences between standard physical therapy (PT) and nonstandard PT strategies for outcomes of balance, gait, and Unified Parkinson's Disease Rating Scale (UPDRS) scores among patients with Parkinson disease (PD). These results suggest that although a wide range of physical therapy for PD have been tested, comparative effectiveness of different models of care and implementation strategies, as well as long-term durability of their outcomes remain undetermined.¹

Overall, the meta-analysis displayed no significant difference for PT compared with no intervention in UPDRS scores (standardized mean difference [SMD], -1.09; 95% CI, -2.50 to 0.33). Similarly, researchers observed no differences for nonstandard PT compared with standard PT in measures of gait (SMD, 0.03; 95% CI, -0.53 to 0.59), balance (SMD, 0.54; 95% CI, -0.03 to 1.12), and UPDRS score (SMD, -0.49; 95% CI, -1.04 to 0.06). Notably, meta-analytic regression of moderators showed no significant differences in outcomes by recurrence of PT per week (SMD, 0.17; 95% CI, -0.03 to 0.36).

“This comprehensive systematic review and meta-analysis revealed that many types of PT have shown benefit in the care of persons with PD. The study also revealed that there are gaps in our understanding of the effects of the type, timing, and frequency of PT for PD care, although maintenance of effect remains largely unexplored. Although a wide range of PT techniques and regimens have been commonly applied, there is scant head-to-head evidence comparing different techniques,” senior author Ramzi G. Salloum, PhD, associate professor and the director of the division of health outcomes and implementation science in the Department of Health Outcomes & Biomedical Informatics at the University of Florida College of Medicine, and colleagues wrote.¹

In this analysis, researchers explored current evidence on the types, timing, frequency, duration, and outcomes of PT regimens applied for patients with PD. Articles published in PubMed, Embase, Medline, and the Web of Science Core Collection between January 1, 2000, and August 10, 2022, were searched. The terms used in the search were related to PD, PT interventions, and PT-related outcomes. The studies included in the analysis were peer-reviewed randomized clinical trials available in English of any PT intervention for PD that had PT-related outcomes. Researchers utilized the Preferred Reporting Items for Systematic Reviews and Meta-analyses as guidelines and had 2 reviewers extract the data and assess the quality using the Cochrane Risk of Bias Tool as well as a random-effects model. Authors then compared outcomes of nonstandard PT with standard PT and standard PT versus no intervention for UPDRS score and measures of gait and balance.

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“Many PT regimens showed improvement in at least 1 area of physical function. We deliberately focused our review on PT and not on exercise therapy. Our review included 5 trials with evidence supporting improvement in a primary outcome that was motor based. There were fewer studies showing benefits of other modalities such as dance and vestibular rehabilitation. This review addressed whether PT outcomes are durable after PT discontinuation, a largely unexplored topic in the literature. Many of the trials addressing this issue reported positive results on longer-term follow-up; however, none of the trials followed up participants for more than 18 months,” Salloum et al.¹

Among 46 trials with 3905 patients (range of mean ages, 61-77 years), 22% (n = 10) compared 2 types of nonstandard PT interventions, 57% (n = 26) had nonstandard PT versus standard PT; and 22% (n = 10) had PT versus no intervention. The most common nonconventional PT intervention was aquatic physiotherapy, included in 11% (n = 5) of trials. The duration of PT regimen ranged between 2 and 12 weeks in 85% (n = 39) of trials (85%).

In 59% (n =27) of trials, PT was most performed with frequencies of either twice or 3 times weekly. Eighty-five percent of trials (n = 39) had PT sessions ranging from 30 to 60 minutes in length. Among the all the trials, gait was reported in 30% (n =14), balance in 22% (n =10), quality of life in 9% (n = 3) and cognition in 2% (n = 1). Approximately 48% (n = 22) of trials recorded durability on some level of benefit following the completion of the prescribed therapy.

“Most trials in this study used PT regimens of 2 to 12 weeks with frequencies of 2 to 3 times weekly and with session lengths of 30 to 60 minutes. Although clinicians may consider this a reasonable standard when prescribing PT, without trial comparators, clinicians can only craft a reasonable guess. In addition, clinicians may be challenged to choose a therapy that will have the best chance for durability of outcome. Further complicating this is the nonsignificant results obtained from our meta-analytic moderator tests of duration, frequency, and number of sessions. Because of the limited number of studies amenable to meta-analysis, it remains unclear whether these factors were truly not associated with outcomes or whether findings were prone to type 2 error. More studies in this area may help to provide clarity,” Salloum et al.¹

All told, limitations of the study include the search missing publications that addressed outcomes other than activities of daily living, quality of life, or motor outcomes. Another noted limitation was the pooling of all trials and subsequent reporting and analyzing all PT parameters for different PT types. In addition, the heterogeneity in PT types, timing, frequencies, and duration and the few numbers of studies that compared these factors was a limitation. Authors noted that only a small portion of trials had adequate long term outcomes to measure the durability of the intervention.

“The findings from this study may inform clinical practice and help physical therapists and physicians to implement PT for PD.However, there are limited data for implementing gamepad-based training for balance or action observation treatment for freezing of gait. More comparative effectiveness research is needed. Also, many clinicians likely will not be aware of whether a facility offers specific interventions that require training or specialized equipment. Home-based exercises might improve access and adherence; however, few outcomes data are available on these regimens and how implementation could be weaved together with direct access to physical therapists or through physician prescriptions,” Salloum et al.¹

REFERENCES
1. El Hayek M, Lobo Jofili Lopes JLM, LeLaurin JH, et al. Type, Timing, Frequency, and Durability of Outcome of Physical Therapy for Parkinson Disease: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(7):e2324860. Published 2023 Jul 3. doi:10.1001/jamanetworkopen.2023.24860