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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum

LE Dibble, O Addison, and E Papa.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The review concluded exercise resulted in improvements in postural stability and balance task performance for people with mild to moderate Parkinson's disease. However, the number and quality of the trials and outcomes were limited. The authors' cautious conclusions reflect the evidence presented, but they were based on few trials, some with small sample sizes, and diverse interventions and outcome measurements.

Authors' objectives

To examine the effects of exercise on balance for people with Parkinson's disease.

Searching

MEDLINE, CINAHL, SPORTDiscus, and the Cochrane Library were searched to May 2008 for studies published in English. Search terms were reported. Google Scholar was also searched. Reference lists of included studies were scanned for additional articles.

Study selection

Controlled clinical trials that evaluated physical activity or exercise interventions aimed at the treatment of idiopathic Parkinson's disease were eligible for inclusion. To be included, trials had to report one of the following outcomes: postural instability, deficits in balance demanding activities or health-related quality of life. Trials that evaluated the immediate effects of sensory cueing strategies or the immediate effect of interventions such as whole body vibration only were excluded.

Interventions varied widely between trials and included muscle strengthening, range of motion, balance training, walking, home based exercise, treadmill training, occupational therapy, relaxation, dance lessons, Qigong, and flexibility training. There was also a wide range of frequency and duration of interventions between trials. Control groups included visit to Parkinson's disease nurse, aerobic exercise, medical therapy only, treadmill, other active intervention or no intervention. The majority of participants were male; mean age ranged from 62 years to 77 years. Severity of Parkinson's disease varied between trials (details reported in review); mean duration of Parkinson's disease ranged from 3.3 years to 10.6 years, where reported. Outcomes included postural instability, balance task performance and health-related quality of life, which were measured by a wide variety of different instruments (details reported in the review).

Three reviewers independently selected studies for inclusion.

Assessment of study quality

Validity was assessed using the American Academy of Cerebral Palsy and Developmental Medicine scale (AACPDM) which assessed the adequacy of: inclusion and exclusion criteria; intervention and adherence; outcome measures; blinding of outcome assessor; power calculation; withdrawals and drop-outs; and methods of controlling for confounding. Trials were rated high quality (6 or more points), moderate quality (4 or 5 points), or low quality (3 or less points). Only studies scoring more than 3 points were included in the review.

Two reviewers independently assessed validity. Discrepancies were resolved by reference to the original article and discussion between reviewers or through recourse to a third reviewer.

Data extraction

Data were extracted on the relevant outcomes independently by two reviewers. Discrepancies were resolved by reference to the original article and discussion between reviewers or through recourse to a third reviewer. Where necessary study authors were contacted for additional information.

Methods of synthesis

Data were grouped by outcome (postural instability, balance task performance and health-related quality of life) and combined in a narrative synthesis.

Results of the review

Sixteen controlled trials were included in the review (700 participants), including two with a crossover design and one with a delayed start design. Sample sizes ranged from 15 to 142. Four trials were rated high quality and the remaining 12 were rated medium quality. Follow-up ranged from two weeks to 12 months.

Body function - postural instability (four trials): There was moderate evidence that exercise improved postural instability for people with mild to moderate Parkinson's disease. Two trials reported significant improvements in exercise groups and one of these trials also reported significant reductions in falls for the exercise group during testing. Two trials reported no statistically significant differences between groups.

Activity - balance task performance (nine trials): There was moderate evidence that exercise produced significant improvements for people with mild to moderate Parkinson's disease in at least one clinical balance measure in all nine trials.

Participation - quality of life (eight studies): There was limited evidence of statistically significant improvements in quality of life for people with mild to moderate Parkinson's disease in the exercise group (two trials): one trial reported a significant decrease in near-falls at both eight weeks and six months post-intervention; and one trial reported a statistically significant decline in quality of life for the exercise group. The remaining trials reported mixed effects post-intervention.

Authors' conclusions

The trials reviewed all reported that exercise resulted in improvements in postural stability and balance task performance for people with mild to moderate Parkinson's disease. Despite these improvements, the number and quality of the trials and outcomes used were limited.

CRD commentary

The review question was broadly defined with appropriate inclusion criteria. Several relevant sources were searched, although limitation to inclusion of only English language trials meant there was the potential of language bias. No attempts appear to have been made to locate unpublished studies, which meant there was also the possibility of publication bias. Appropriate efforts were made to reduce reviewer error and bias in all stages of the review process.

Validity was assessed using appropriate criteria, and results of the assessment were reported and informed the synthesis. A narrative synthesis was appropriate given the diversity of the included trials in terms of interventions and outcomes.

The authors' cautious conclusions reflect the evidence presented, but it should be borne in mind that they were based on few studies, some with small samples, and diverse interventions and outcome measurements.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that there is a need for longer-term follow-up to establish the trajectory of change and to determine whether improvements remain in the long term. In addition, further research should evaluate optimal delivery and content of exercise interventions at different stages of disease, include more women, and use sensitive and reliable outcome measures, including biomechanical measures.

Funding

Not stated.

Bibliographic details

Dibble LE, Addison O, Papa E. The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum. Journal of Neurologic Physical Therapy 2009; 33(1): 14-26. [PubMed: 19265767]

Indexing Status

Subject indexing assigned by NLM

MeSH

Exercise Therapy /methods; Humans; Motor Activity; Neuropsychological Tests /standards; Parkinson Disease /physiopathology /therapy; Postural Balance; Psychomotor Performance; Quality of Life; Treatment Outcome

AccessionNumber

12009105276

Database entry date

22/09/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19265767

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