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Movement Disorders

Vol. 22, No. 4, 2007, pp. 451 460

2006 Movement Disorder Society CME


Evidence-Based Analysis of Physical Therapy in Parkinsons

Disease with Recommendations for Practice and Research

Samyra H.J. Keus, PT, MSc,1 Bastiaan R. Bloem, MD, PhD,2* Erik J.M. Hendriks, PT, PhD,3,4
Alexandra B. Bredero-Cohen,3 and Marten Munneke, PT, PhD,2,5 on behalf of the
Practice Recommendations Development Group
Department of Physical Therapy, Leiden University Medical Center (LUMC), The Netherlands
Department of Neurology, Radboud University Nijmegen Medical Centre (RUNMC), The Netherlands
Department of Research and Development, Dutch Institute of Allied Health Care (NPi), The Netherlands
Department of Epidemiology, and Center for Evidence Based Physiotherapy (CEBP), Maastricht University, The Netherlands
Research Centre of Allied Health Care, Department of Physical Therapy, RUNMC, The Netherlands

Abstract: Physical therapy is often prescribed in Parkinsons tions that were based on evidence from more than two con-
disease. To facilitate the uniformity and efcacy of this inter- trolled trials: cueing strategies to improve gait; cognitive move-
vention, we analyzed current evidence and developed practice ment strategies to improve transfers; exercises to improve
recommendations. We carried out an evidence-based literature balance; and training of joint mobility and muscle power to
review. The results were supplemented with clinical expertise improve physical capacity. These practice recommendations
and patient values and translated into practice recommenda- provide a basis for current physical therapy in Parkinsons
tions, developed according to international standards for guide- disease in everyday clinical practice, as well as for future
line development. A systematic literature search yielded 6 research in this eld. 2006 Movement Disorder Society
systematic reviews and 23 randomized controlled trials of Key words: practice guideline; physical therapy; Parkinson
moderate methodological quality with sufcient data. Six spe-
disease; evidence-based medicine; International Classication
cic core areas for physical therapy were identied: transfers,
of Functioning, Disability, and Health (ICF); activities of daily
posture, reaching and grasping, balance, gait, and physical
capacity. We extracted four specic treatment recommenda- living

In the course of their disease, most patients with pendence, (fear of) falls, injuries, and inactivity,
Parkinsons disease (PD) face mounting mobility de- resulting in social isolation and an increased risk of
cits, including difculties with transfers, posture, bal- osteoporosis or cardiovascular disease.1,2 Consequently,
ance, and walking. This frequently leads to loss of inde- costs increase3 and quality of life decreases.4 These mo-
bility decits are difcult to treat with drugs or
This article is part of the journals CME program. The CME form
can be found on page 600 and is available online at http://www. Physical therapy is often prescribed next to medical treatment.7 However, there are presently no guidelines
Members of the Practice Recommendations Development Group are for physical therapy in PD with practical recommenda-
listed in the Appendix.
*Correspondence to: Dr. Bastiaan R. Bloem, Radboud University
Nijmegen Medical Centre, Institute of Neurology (935), PO Box 9101,

6500 HB Nijmegen, The Netherlands. E-mail: In the Netherlands, physical therapists, Cesar exercise therapists,
Received 9 October 2005; Revised 9 August 2006; Accepted 10 and Mensendieck exercise therapists can deliver exercise therapy. The
August 2006 term physical therapy in this study also includes Cesar and Mensen-
Published online 28 November 2006 in Wiley InterScience (www. dieck exercise therapies; the term physical therapist in this study also DOI: 10.1002/mds.21244 includes Cesar and Mensendieck exercise therapists.

452 S.H.J. KEUS ET AL.

TABLE 1. EBRO classication of study results and examination, outcome assessment, and treatment out-
recommendations: classication of the study results come. Furthermore, cross-references and expert recom-
according to the level of evidence
mended references were evaluated. To be selected, pub-
A1 Meta-analyses (systematic reviews), which include at least lications had to address physical therapy in PD and be
some, randomized clinical trials at quality level A2 that published in English, Dutch, or German. Trials were only
show consistent results between studies
A2 Randomized clinical trials of a good methodological quality selected if sufcient data were reported.
(randomized double-blind controlled studies) with sufcient
power and consistency Levels of Evidence
B Randomized clinical trials of a moderate methodological
quality or with insufcient power, or other nonrandomized, The selected literature was critically appraised by as-
cohort or patientcontrol group study designs that involve sessing the quality of the study design. When evidence
intergroup comparisons was not available in published studies, recommendations
C Patient series
D Expert opinion were formulated based on consensus among group mem-
bers. Evidence was graded according to EBRO recom-
mendations (Table 1). EBRO is an initiative of the Dutch
Cochrane Center and the Dutch Institute for Healthcare
tions graded according to scientic evidence. Prior re-
Improvement (CBO,, a member of
search was hampered by this lack of uniform treatment
the Guidelines International Network (GIN). Consensus
recommendations.8 10 Therefore, we developed evi-
was gained by means of informative meetings, Delphi
dence-based practice recommendations according to in-
rounds, Web-based discussions, and consensus-meet-
ternational criteria for guideline development.11,12 With
ings. Finally, practice recommendations were graded
these recommendations we aim to facilitate the unifor-
based on their levels of evidence (Table 2).
mity and efcacy of physical therapy in PD. Further-
more, practice recommendations provide referring phy- Identied Literature
sicians insight into the possibilities and limitations of The literature searches yielded six systematic re-
physical therapy in PD, thereby promoting the quality of views8 10,1315 and 23 controlled (level B) studies with
referrals. Finally, the recommendations can provide a sufcient data on the effectiveness of physical therapy in
rm basis for future research in this eld. PD.16 39 One of these studies was covered in two pub-
Here, we describe the systematic analysis of evidence lications.29,30 Another six controlled studies could not be
and the key recommendations. For detailed recommen- included due to insufcient data.40 45
dations on referral indications and treatment options, we
refer to a comprehensive description that is available EXTRACTING PRACTICE
EVIDENCE-BASED LITERATURE REVIEW On the basis of the systematic literature search, prac-
tice recommendations were deduced according to inter-
Search Strategy and Selection Criteria national standards for guideline development.11,12 A na-
First, a systematic literature search for guidelines, tional Practice Recommendations Development Group
systematic reviews, trials, and expert opinions was per- of 9 expert physical therapists and 1 expert neurologist,
formed in the electronic databases of Medline, Cinahl, as well as a Steering Committee that guarded the devel-
Embase, and the Cochrane Library in May 2002. As opment process, were installed in December 2001.
insights may evolve over time, expert opinions were only
included when published after May 1997. Randomized
controlled trials (RCTs), controlled clinical trials TABLE 2. EBRO classication of study results and
(CCTs), and pre-experimental studies were identied recommendations: classication of the recommendations
according to the level of evidence
using combinations of the following medical subject
heading (MeSH) headings and free texts: Parkinsons Level
disease, physical therapy, physical therapy techniques, 1 Supported by one systematic review at quality level A1 or
exercise movement techniques, exercise, exercise ther- at least two independent trials at quality level A2
apy, physiotherapy, and training. To identify clinical 2 Supported by at least two independent trials at quality
level B
measurements for baseline assessment and treatment 3 Supported by one trial at quality level A2 or B, or
evaluation purposes, combinations of the following research at quality level C
[MeSH] headings and free texts were used: Parkinson 4 Based on the expert opinion (e.g., of working group
disease, sensitivity and specicity, exercise test, physical

Movement Disorders, Vol. 22, No. 4, 2007


Clinical Expertise and Patient Values phase is characterized by specic physical therapy goals
An independent, international Review Panel of 16 and interventions within the six core areas. In the suc-
professionals with specic expertise in movement disor- cessive phases, the goals and interventions of the fore-
ders (e.g., neurologist, general practitioner, physical ther- going phase(s) might remain valid.
apist, and occupational therapist) reviewed a draft of the
Clinical Measurements
practice recommendations. Finally, a Patient Panel of the
Dutch Parkinsons Disease Association reviewed a draft We selected clinical measurements (both quantitative
of the practice recommendations. The key question was and qualitative) for baseline assessment and treatment
Would your physical therapist be able to optimally treat evaluation purposes. In physical therapy, the most suit-
you and the problems you experience due to your Par- able instruments are linked to the ICF domain of level of
kinsons disease, if he had a copy of this manuscript?. limitations (in activities).47,48 Instruments were selected
The Practice Recommendations Development Group dis- based on ICF level, feasibility, and clinimetric proper-
cussed the collected drawbacks and strengths of the ties: reliability; validity; and responsiveness.
recommendations until consensus was reached. Finally, Three instruments are recommended for use in all
the literature search was updated in October 2003. Newly patients: a patient preference disability questionnaire (to
found evidence was graded according to the EBRO cri- identify patient-specic complaints) for baseline assess-
teria and, after consensus was reached, incorporated into ment and treatment evaluation purposes49,50; a structured
the recommendations. falls history questionnaire for baseline assessment pur-
poses51; and the global perceived effect for treatment
PRACTICE RECOMMENDATIONS evaluation purposes. Although the selection of these
three instruments was based on consensus within the
Core Areas Practice Recommendations Development Group, other
Physical therapy is unlikely to inuence the disease instruments may also be appropriate as a systematic
process itself but can improve daily functioning by approach to determine best examination tools was not
teaching and training PD patients in the use of (compen- undertaken.
satory) movement strategies. Furthermore, physical ther- PD patients with more than one fall in the previous
apy may inuence secondary health problems, e.g., (risk year are likely to fall again within the next 3 months.
of) decreased strength or endurance. This falling can lead to fractures or other physical injury
Six specic core areas for physical therapy in PD were and to (more) fear to move, resulting in decreased activ-
identied (in random order): (1) Transfers (e.g., turning ities and an increased liability to renewed falls. Most
in bed or rising from a chair), (2) Posture (including neck falls in PD occur during transfers, such as rising from a
and back problems), (3) Reaching and grasping, (4) chair, and during (freezing of) gait.51,52 Therefore, fall
Balance and falls (including fear of falling), (5) Gait, (6) circumstances should be adequately screened to guaran-
Physical capacity and (in)activity. tee that interventions are tailored to the patients specic
fall circumstances.
History Taking and Physical Examination Repeated clinical evaluations should always be per-
The practice recommendations contain a quick refer- formed while the patient is in a comparable clinical state
ence card for history taking and physical examination. (e.g., always at the same time after medication intake, or
During history taking, the physical therapist should sys- standardized for on and off periods). Depending on the
tematically assess health problems on all levels of the patient-specic treatment goals and the patients motiva-
International Classication of Functioning, Disability tion, treatment should be nished when the goals are
and Health (ICF). The outcome of the history taking and reached, or when the therapist concludes that physical
physical assessment determines the core area(s) for treat- therapy no longer has additional value (e.g., the goals are
ment. Finally, the therapist should examine the patients unreachable, or the patient can achieve the goals
expectations regarding treatment, particularly whether unsupervised).
these are realistic. On the basis of the results of the
history taking and physical examination, the therapist Key Recommendations for Physical Therapy
determines whether physical therapy is indicated and, if Intervention
so, draws a treatment plan. The Practice Recommenda- Of all practice recommendations provided, four were
tions Development Group has identied three phases in based on evidence from two or more controlled trials
the course of the disease: early, middle, late (Fig. 1). (Tables 35) and, therefore, reach level 2 recommen-
These phases are based on the model of Kamsma.46 Each dation (Table 2): (I) Application of cueing strategies to

Movement Disorders, Vol. 22, No. 4, 2007

454 S.H.J. KEUS ET AL.

FIG. 1. Phases in the course of Parkinsons disease

(PD): goals and possible interventions for physical ther-
apy in Parkinsons disease

improve gait; (II) Application of cognitive movement speed as measured with the Ten-meter Walk Test.53
strategies to improve transfers; (III) Specic exercises to One off cues are used as a focusing point to maintain
improve balance; (IV) Training of joint mobility and balance, and for initiating activities of daily life (ADL;
muscle power to improve physical capacity. e.g., start walking after a period of freezing, or rising
from a chair).
I. Cueing strategies Cues can be divided into four groups: Auditory
It is plausible that, in patients with PD, gait is im- cues,21,27,30,31,37,54 56 e.g., the use of a walkman with
proved by applying visual or auditory cues, which have rhythmic music, a metronome, or counting (by the pa-
been trained during active gait training.31,37 Cues are tient, partner, or caretaker); Visual cues,27,30,31,55,57 60
stimuli from the environment or generated by the patient, e.g., stepping over stripes on the oor or over the grip of
which the patient uses, consciously or not, to facilitate an inverted walking stick, or focusing on an object (e.g.,
(automatic and repetitive) movements. It is not yet clear a clock) in the environment; Tactile cues,27,30 e.g., tap-
exactly how cues improve movement. Perhaps they pro- ping on the hip or the leg; Cognitive cues,21,60 e.g., a
vide an external rhythm that can compensate for the mental image of the appropriate step length.
improperly supplied internal rhythm of the basal ganglia,
correct the motor set deciency, or (in case of visual II. Cognitive movement strategies
cues) generate optical ow that activates a cerebellar It is plausible that, in patients with PD, applying
visualmotor pathway.15 Not all patients benet equally cognitive movement strategies improves the perfor-
from using cues. mance of transfers.26,31 In this strategy, complex auto-
A distinction is made between rhythmical cues and mated movements are transformed into a series of sub-
one off cues. Rhythmical cues are given as a contin- movements that have to be executed in a xed order. All
uous, serial set of stimuli, which can serve as a control elements consist of relatively simple movement compo-
mechanism to pace walking. The frequency of rhythmi- nents. The course of the movement is thereby reorga-
cal cues is based on the patients comfortable walking nized in such a way that the activity can be performed

Movement Disorders, Vol. 22, No. 4, 2007


TABLE 3. Identied level B studies (EBRO criteria) on the effectiveness of physical therapy in Parkinsons disease used for the
key recommendations: RCT of PT versus no intervention
Reference, No.a Design No. of
year of publication (E,C) Hoehn & Yahr Experimental intervention Duration sessions Group effect
Bergen et al. (16), 8 (4,4) Parallel Exercises to improve physical 16 weeks (22 hr) 48 VO2-max
2002 H&Y 2 capacity Leg strength
Comella et al. (18), 18 Cross-over Exercises for ROM, gait, 4 weeks (12 hr) 12 UPDRS: total, ADL,
1994 H&Y 2 to 3 balance, dexterity, and motor
physical capacity
(proprioceptive neuromuscular
facilitation); Additional: OT
Gauthier et al. (21), 64 (33,31) Parallel Exercises for ROM, dexterity, 5 weeks (20 hr) 10 ADL (BI)
1987 H&Y 2 to 4 ADL, balance, posture, and
gait (visual and auditory cues);
Education; Additional: OT,
dietician, SW, psychologist
Patti et al. (34), 1996 20 (12,8) Parallel Active and passive exercises for 4 weeks ADL (BI, FIM)
H&Y 2 to 3 ROM, balance, gait (e.g. Gait: speed, step
auditory cues), and antirigidity. length
Additional: OT for self-care;
Speech therapy for swallowing
UPDRS: total
Schenkman et al. (35), 51 (27,24) Parallel Active exercises for (axial) ROM 10 weeks (22.5 30 Functional axial
1998 H&Y 2 to 3 and coordinated movement to 30 hr) rotation
incorporated in ADL Functional reach
Toole et al. (38), 2000 11 (6,5) Parallel Active exercises for strength of 10 (30 hr) 30 Leg strength
H&Y 1 to 4 knee (tness equipment) and Balance (sway)
ankle (resistive elastic bands),
and balance (pro- and
retropulsion tests, balance on
Dropouts included.
RCT, randomized controlled trial; PT, physical therapy; E, experimental group; C, control group; VO2-max, maximum oxygen consumption; ROM,
range of motion; ADL, activities of daily life; OT, occupational therapy, SW, social work; H&Y, Hoehn & Yahr; UPDRS, Unied Parkinsons Disease
Rating Scale; BI, Barthel Index; FIM, Functional Independence Measure.

consciously. The fundamental problem of disturbed in- be prepared mentally. The newly learned movement se-
ternal control (in particular the inability of the basal quence does not become automated, but performance
ganglia to automatically program sequential movements) remains under conscious control and can be guided by
is thus bypassed. Before execution, the movement should the application of cues for initiation.29,30

TABLE 4. Identied level B studies (EBRO criteria) on the effectiveness of physical therapy in Parkinsons disease used for the
key recommendations: NRCT of PT versus no intervention
Reference, No. Hoehn & No. of
year of publication (E,C) Yahr Experimental intervention Duration sessions Group effect
Bridgewater and Sharpe (17), 26 (13,13) Parallel H&Y Exercises for strength trunk muscles 12 weeks 24 Rotational
1997 1 to 3 (respiration, posture) in different (14 hr) strength trunk
positions (prone, back, and on ADL (NUDS,
hands and knees) HAP)
Formisano et al. (20), 1992 33 (16,17) Parallel H&Y Passive exercises for ROM, active 17 weeks 51 Gait: speed
2 to 3 exercises for posture, balance, (51 hr) ADL (NUDS)
coordination, gait, dexterity, and
Nieuwboer et al. (31), 2001 33 Within-subject Active home-based exercises 6 weeks 18 ADL (PAS)
H&Y 2 to 3 strategies for transfers (cognitive (9 hr) Gait: step
movement strategies) and gait length
(visual and auditory cues)

NRCT, nonrandomized controlled trial; PT, physical therapy; E, experimental group; C, control group; ROM, range of motion; ADL, activities of
daily life; H&Y, Hoehn & Yahr; NUDS, Northwestern University Disability Scale; HAP, Human Activity Prole; PAS, Parkinson Activity Scale.

Movement Disorders, Vol. 22, No. 4, 2007

456 S.H.J. KEUS ET AL.

TABLE 5. Identied level B studies (EBRO criteria) on the effectiveness of physical therapy in Parkinsons disease used for the
key recommendations: RCT of PT versus placebo-controlled
Reference, No.a Hoehn & Control No. of
year publication (E,C) Yahr Experimental intervention intervention Duration sessions Group effect
Hirsch et al. (24), 15 (6,9) Parallel Active exercises for ankle Exercises for 10 weeks 30 Balance
2003 E: H&Y and knee strength balance (see (22.5 hr) Leg strength
1.90.6 (tness equipment, E) Instrumental ADL
C: H&Y resistive elastic bands), (e.g., housekeeping)
1.80.3 and balance (pro- and
retropulsion tests,
balance and weight-
shifting on foam)
Hurwitz (25), 30 (15,15) Parallel Exercises for ROM, Weekly 32 weeks 32 Memory, eating,
1989 H&Y mobility, and self-care assessment, no (16 hr) incontinence
1 to 3 exercise
Kamsma et al. 38 (25,13) Parallel Exercises (cognitive Exercises for 1 year (8 1st: 8 ADL, physical
(26), 1995 H&Y movement strategies) physical 29 hr) 2nd: functioning, coping;
2 to 4 for gait and transfers capacity and 29 UPDRS (bed, chair
(e.g. rising from a ROM mobility)
chair, bed mobility)
Marchese et al. 20 (10,10) Parallel Exercises for (axial) Equal, without 6 weeks (18 18 UPDRS: motor
(27), 2000 H&Y ROM, posture, and cues hr)
1.5 to 3 gait (visual and
auditory cues)
Mohr et al. (29), 41(20,21) Parallel Group exercises (external Group exercises 10 weeks 20 UPDRS: motor (e.g.,
1996 H&Y cues and cognitive for respiration; (30 hr) rising from chair)
Muller et al. 1.5 to 4 movement strategies) Disease Gait: initiation,
(30), 1997 for gait, transfers, and specic postural stability
relaxation information Dexterity
Stallibrass et al. 93 (32,31/30) Parallel Alexander technique Manual contact 12 weeks 24 ADL (SPDDS) (versus
(36), 2002 H&Y to the skin and (16 hr) C2) Depression
unknown personal (BDI) (versus C2)
attention (C1);
none (C2)
Thaut et al. (37), 26 (15,11/11) Parallel Gait training with weekly Self-paced gait 3 weeks 21 Gait: speed; stride
1996 H&Y increased rhythm training (C1); (10.5 hr) length (versus C2)
mean (auditory cues) none (C2) Cadence (versus C1)
Dropouts included.
RCT, randomized controlled trial; PT, physical therapy; E, experimental group; C, control group; ROM, range of motion; ADL, activities of daily
life; OT, occupational therapy, SW, social work; H&Y, Hoehn & Yahr; UPDRS, Unied Parkinsons Disease Rating Scale; BDI, Beck Depression
Inventory; SPDDS, Self-assessment Parkinsons Disease Disability Scale.

III. Balance partner or caretaker; recognize on and off periods; pref-

It is plausible that balance training (where patients are erentially select functional exercises; avoid dual tasking;
taught to use visual and vestibular feedback), combined and evaluate treatment outcome every 4 weeks, to decide
with lower limb strength training, is effective in improv- whether the intervention needs to be continued, adjusted,
ing balance in patients with PD, and more effective than or terminated.
balance exercises alone.24,38
IV. Physical capacity
The practice recommendations manuscript has been
It is plausible that an exercise program aimed at im-
transformed into a formal guideline for physiotherapy in
proving range of motion combined with activity-related
Parkinsons disease.61 The guideline informs neurolo-
(e.g., gait or balance) exercises, improves ADL function-
ing.18,20,27,32,33 Furthermore, it is plausible that, in PD, a gists about the indication for referral to physical therapy,
strength-training program increases muscle power.17,24,36 and informs therapists about possibilities and limitations
of physical therapy in PD.
Additional Recommendations This guideline consists of brief practice recommenda-
A broad range of level 3 and level 4 recommendations tions (nine pages), a detailed review of the evidence (34
is provided, including specic recommendations (tai- pages, excluding references and supplements), and four
lored to the core areas) and more general recommenda- quick reference cards concisely describing the history
tions. The patient-specic treatment goals determine taking, physical examination, instruments for baseline
which recommendations are best addressed. Examples of assessment and treatment evaluation purposes, and the
general recommendations are as follows: involve the disease-specic treatment strategies. Furthermore, a pa-

Movement Disorders, Vol. 22, No. 4, 2007


tient information leaet is provided. The manuscript will systematic reviews8 10 had reasonable quality; the others
be scrutinized within 5 years, and updated if necessary. had moderate13,14 or poor15 quality. Furthermore, the
specic physical therapy interventions that were evalu-
Formal Approval ated in different studies varied widely. This nding is not
The practice recommendations were formally ap- surprising, because evidence-based practice guidelines
proved and disseminated by the Royal Dutch Society for were unavailable until now. An important step was made
Physical Therapy as their ofcial guideline. The full by expert physical therapists in the UK who developed a
practice recommendations are available in Dutch and guideline of physical therapy in PD.83 Although this
English ( and guideline provides an extensive overview of the eld, it
The Association of Physiotherapists in Parkinsons Dis- was not systematically developed according to interna-
ease Europe (APPDE, endorses tional standards for guideline development. For example,
the practice recommendations and supports their interna- referring physicians and patients were not involved in the
tional implementation and evaluation. development process. The current practice recommenda-
tions were systematically developed according to ac-
Field Test cepted international criteria,11,12 and are reproducible. By
The practice recommendations were eld tested for 4 integrating the best available research evidence with
months by 70 physical therapists who were not involved clinical expertise and patient values, we have developed
in the development process. In this eld test, therapists clinical practice recommendations that facilitate evi-
thoroughly studied the practice recommendations and dence-based health care for physical therapy in PD.
subsequently applied it in ongoing or newly started treat- These recommendations provide a rm basis for current
ments of PD patients. Therapists completed a question- physical therapy practice in PD, as well as for future
naire on the overall comprehensibility of the practice research in this eld. Our suggestion is that future re-
recommendations, on the applicability in everyday clin- search should further address the use of cues and move-
ical practice, on the feasibility of the recommended mea- ment strategies. For instance, we need to known for
suring instruments, and on any discrepancies between the which subgroups of PD patients cues and movement
recommendations and everyday clinical practice. Physi- strategies are most effective. In addition, we need to
cal therapists could also provide additional comments to further clarify how cues and movement strategies might
improve the practice recommendations. Simultaneously, prevent freezing and falls in PD. Another research topic
a draft of the practice recommendations was evaluated in is the safety problems (e.g., falls) caused by executing
a feasibility study.62 The Practice Recommendations De- dual tasks in relation to physiotherapy interventions. For
velopment Group discussed the collected drawbacks and instance, can the performance of dual tasks be trained
strengths of the recommendations until consensus was and, if so, how? Pain and fatigue are also issues of
reached. common clinical concern. Evidence concerning physio-
therapy interventions dealing with these issues is limited
Update of Latest Evidence and should be enlarged. Finally, there is a need to eval-
For our guideline (published in 2004), literature pub- uate how physiotherapy guidelines can be implemented
lished until October 2003 was reviewed. We have re- effectively into everyday clinical practice. Do Parkinson
peated the literature search for all studies published until patients benet from implementation of the guideline?
June 2006. Several papers have appeared since the pub- Future research requires appropriate methods to optimize
lication of the guideline.63 81 An analysis of these studies the scientic value. An important methodological issue
demonstrates that the level of evidence of the recommen- that needs to be addressed is the use of appropriate
dations provided in our guideline is not altered by the outcome measures with particular relevance to patients,
results of these studies. their carers, physiotherapists, and physicians. Further-
more, prospective intervention studies should include a
CONCLUSION AND FUTURE DIRECTIONS sufcient number of participants, and these patients need
to be followed for at least 6 months to determine the
Evidence-Based Health Care duration of any improvement.
There are indications that physical therapy might be
effective in PD.82 However, the evidence is inconclusive. Implementation of Practice Recommendations
This nding is due to the small number of patients We have developed a multifaceted implementation
enrolled in the studies, the methodological aws in many strategy: creation of regional networks of expert physical
studies, and the possibility of publication bias. Three therapists with specic training in PD (ParkNet), who are

Movement Disorders, Vol. 22, No. 4, 2007

458 S.H.J. KEUS ET AL.

offered continuous education, improved communication 2. Garrett NA, Brasure M, Schmitz KH, Schultz MM, Huber MR.
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implementation of these practice recommendations.84 general population. Mov Disord 2000;15:11121118.
5. Management of Parkinsons disease: an evidence-based review.
Acknowledgments: We thank Professor R.A.C. Roos, MD, Mov Disord 2002;17(Suppl. 4):S1S166.
PhD (Department of Neurology, LUMC, The Netherlands) for 6. Bloem BR, Beckley DJ, van Dijk JG, Zwinderman AH, Remler
MP, Roos RA. Inuence of dopaminergic medication on automatic
critical comments on this article; the Patient Panel for review-
postural responses and balance impairment in Parkinsons disease.
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who participated in the eld test; and the members of the 7. Keus SHJ, Bloem BR, Verbaan D, et al. Physiotherapy in Parkin-
Steering Committee for guarding the development process: M. sons disease: utilisation and patient satisfaction. J Neurol 2004;
Heldoorn, PhD and A.L.V. Verhoeven (Royal Dutch Society 251:680 687.
for Physical Therapy, KNGF); E. de Jong and M. van Gennep 8. Goede CJ, de, Keus SH, Kwakkel G, Wagenaar RC. The effects of
(Dutch Society for Physical Therapy in Geriatrics), Ms. J. van physical therapy in Parkinsons disease: a research synthesis. Arch
Sonsbeek, MSc (Dutch Society for Mensendieck Exercise Phys Med Rehabil 2001;82:509 515.
Therapy, NVOM), Ms. H. Verburg (Cesar Kinesiology Society, 9. Deane KH, Jones D, Playford ED, Ben Shlomo Y, Clarke CE.
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VBC), and P. Hoogendoorn, MSc (Dutch Parkinsons Disease
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kinson Patienten Vereniging), the Royal Dutch Society for 10. Deane KHO, Ellis-Hill C, Clarke CE, Playford ED, Ben-Shlomo
Physical Therapy, and the Dutch Society for Mensendieck and Y. Physiotherapy for Parkinsons disease: a comparison of tech-
Cesar Exercise Therapy (VvOCM) funded the development of niques (Cochrane review). The Cochrane Library, (Issue 2). 2002
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in the preparation of this review or the decision to submit this 11. Hendriks HJM, Bekkering GE, van Ettekoven H, Brandsma JW,
review for publication. van der Wees PhJ, de Bie RA. Development and implementation of
national practice guidelines: a prospect for continuous quality
APPENDIX improvement in physiotherapy. Introduction to the method of
guideline development. Physiotherapy 2000;86:535547.
The following are members of the Practice Recommendations De- 12. The AGREE Collaboration. Appraisal of Guidelines for Research
velopment Group. B.R. Bloem, PhD (neurologist, RUNMC); C.J.T. de & Evaluation (AGREE) Instrument. 2001. Available at: http://
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versity Medical Center); Ms. M. van Haaren (physical therapist, Re- 13. Deane KHO, Ellis-Hill C, Jones D, et al. Systematic review of
habilitation Centre Breda); H.J.M. Hendriks, PhD (physical therapist, paramedical therapies for Parkinsons disease. Mov Disord 2002;
health scientist, clinical epidemiologist, Dutch Institute of Allied 17:984 991.
Health Care, Centre for Evidence Based Physiotherapy); Ms. M. Jas- 14. Nieuwboer A, De Weerdt W, Nuyens G, Hantson L, Feys H.
pers (Mensendieck exercise therapist, Fysio Ludinge); Y.P.T. Kamsma, Review of the efcacy of physiotherapy in Parkinsons disease
PhD (physical therapist, human movement scientist, Center for Human [Een literatuurstudie naar de effecten van fysiotherapie bij de
Movement Sciences); Ms. S.H.J. Keus, MSc (physical therapist, human ziekte van Parkinson]. Ned Tijdschr Fysiother 1994;5:122128.
movement scientist, LUMC); M. Munneke, PhD (physical therapist, 15. Rubinstein TC. Giladi N, Hausdorff JM. The power of cueing to
human movement scientist, clinical epidemiologist, RUNMC); Ms. J. circumvent dopamine decits: a review of physical therapy treat-
Westra (physical therapist, Nursing home Maartenshof); and B.Y. de ment of gait disturbances in Parkinsons disease. Mov Disord
Wolff, MSc (Cesar exercise therapist, Medical Center De Vecht). 2002;17:1148 1160.
Members of the Review Panel (Expert Professionals) are as follows. 16. Bergen JL, Toole T, Elliott III RG, Wallace B, Robinson K,
Ms. A. Coerts (speech therapist, Spaarne Hospital); Ms. Y. van den Maitland CG. Aerobic exercise intervention improves aerobic ca-
Elzen-Pijnenburg (occupational therapist, RUNMC); AN Goudswaard, pacity and movement initiation in Parkinsons disease patients.
PhD (general practitioner, Dutch College of General Practitioners); J.J. NeuroRehabilitation 2002;17:161168.
van Hilten, PhD (neurologist, LUMC); Ms. D. Jones, PhD (physical 17. Bridgewater KJ, Sharpe M. Trunk muscle training and early Par-
therapist, Northumbria University, UK); R. Koopmans, PhD (nursing kinsons disease. Physiother Th Pract 1997;13:139 153.
home physician, RUNMC); G. Kuijpers, MD (rehabilitation physician, 18. Comella CL, Stebbins GT, Brown-Toms N, Goetz CG. Physical
Rehabilitation Centre Breda); G. Kwakkel, PhD (physical therapist, therapy and Parkinsons disease: a controlled clinical trial. Neu-
human movement scientist, VU University Medical Centre); Ms. A. rology 1994;44(Pt 1):376 378.
Nieuwboer, PhD (physical therapist, Catholic University Leuven, Bel- 19. Dam M, Tonin P, Casson S, et al. Effects of conventional and
gium); Ms. L. Rochester, PhD (physical therapist, Northumbria Uni- sensory-enhanced physiotherapy on disability of Parkinsons dis-
versity, UK); K.P.M. van Spaendonck, PhD (neuro-psychologist, ease patients. Adv Neurol 1996;69:551555.
RUNMC); Ms. M.M. Samson, PhD (geriatrician, UMC Utrecht); J.D. 20. Formisano R, Pratesi L, Modarelli FT, Bonifati V, Meco G. Re-
Speelman, PhD (neurologist, AMC); F. Vreeling, PhD (neurologist, habilitation and Parkinsons disease. Scand J Rehabil Med 1992;
Maastricht University); and Ms. S. Vernooy and Ms. C. van der 24:157160.
Bruggen-De Vries (Cesar exercise therapists, Scheper Hospital). 21. Gauthier L, Dalziel S, Gauthier S. The benets of group occupa-
tional therapy for patients with Parkinsons disease. Am J Occup
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