Physiotherapy for Parkinson’s disease: defining evidence within a framework for intervention

Abstract

SUMMARY Parkinson’s disease (PD) is a complex multisystem disorder presenting with motor and non-motor deficits in function. Current medical management addresses the symptoms of PD pharmacologically and surgically and targets mainly the dopaminergic system. Symptoms that are not responsive or become resistant to dopamine remain poorly controlled such as gait, postural instability and falls. Management of these problems often falls to the physiotherapist, raising questions as to the nature and evidence for practice. It is clear that evidence to support physiotherapy in the management of PD is accumulating exponentially. However, the heterogenous nature of interventions and trials creates difficulty when applying evidence in the clinical setting. We present a clinical framework to identify and review evidence for the key therapeutic approaches in PD, which we describe as exercise and movement strategy training. Evidence is restricted to that from randomized clinical trials. We argue that physiotherapy efficacy is well established, and the challenge now is to refine its application through the apposite use of selected exercise and movement strategies; consideration of dose intensity; subpopulation; concern for non-motor symptoms; and regard for the course of the disease. We highlight current developments in the evidence that emphasize the potential for motor learning and neuroplasticity. Finally, implications for clinical management, including tools to aid implementation of the evidence and advice for referral, are discussed and recommendations for future work made.