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Physiotherapy intervention in Parkinson’s disease: systematic review and meta-analysis

BMJ 2012; 345 doi: (Published 06 August 2012) Cite this as: BMJ 2012;345:e5004
  1. Claire L Tomlinson, systematic reviewer1,
  2. Smitaa Patel, statistician1,
  3. Charmaine Meek, research assistant1,
  4. Clare P Herd, research associate2,
  5. Carl E Clarke, professor23,
  6. Rebecca Stowe, senior systematic reviewer1,
  7. Laila Shah, research administrator1,
  8. Catherine Sackley, professor of physiotherapy research4,
  9. Katherine H O Deane, senior lecturer in research4,
  10. Keith Wheatley, professor5,
  11. Natalie Ives, senior statistician1
  1. 1Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
  2. 2School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham
  3. 3Department of Neurology, Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham
  4. 4University of East Anglia, Norwich, UK
  5. 5Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, University of Birmingham
  1. Correspondence to: C Tomlinson c.l.smith.1{at}
  • Accepted 4 July 2012


Objective To assess the effectiveness of physiotherapy compared with no intervention in patients with Parkinson’s disease.

Design Systematic review and meta-analysis of randomised controlled trials.

Data sources Literature databases, trial registries, journals, abstract books, and conference proceedings, and reference lists, searched up to the end of January 2012.

Review methods Randomised controlled trials comparing physiotherapy with no intervention in patients with Parkinson’s disease were eligible. Two authors independently abstracted data from each trial. Standard meta-analysis methods were used to assess the effectiveness of physiotherapy compared with no intervention. Tests for heterogeneity were used to assess for differences in treatment effect across different physiotherapy interventions used. Outcome measures were gait, functional mobility and balance, falls, clinician rated impairment and disability measures, patient rated quality of life, adverse events, compliance, and economic analysis outcomes.

Results 39 trials of 1827 participants met the inclusion criteria, of which 29 trials provided data for the meta-analyses. Significant benefit from physiotherapy was reported for nine of 18 outcomes assessed. Outcomes which may be clinically significant were speed (0.04 m/s, 95% confidence interval 0.02 to 0.06, P<0.001), Berg balance scale (3.71 points, 2.30 to 5.11, P<0.001), and scores on the unified Parkinson’s disease rating scale (total score −6.15 points, −8.57 to −3.73, P<0.001; activities of daily living subscore −1.36, −2.41 to −0.30, P=0.01; motor subscore −5.01, −6.30 to −3.72, P<0.001). Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the interventions for any outcomes assessed, apart from motor subscores on the unified Parkinson’s disease rating scale (in which one trial was found to be the cause of the heterogeneity).

Conclusions Physiotherapy has short term benefits in Parkinson’s disease. A wide range of physiotherapy techniques are currently used to treat Parkinson’s disease, with little difference in treatment effects. Large, well designed, randomised controlled trials with improved methodology and reporting are needed to assess the efficacy and cost effectiveness of physiotherapy for treating Parkinson’s disease in the longer term.


  • We thank all the original trialists and people who performed the trials that contributed to this meta-analysis; the patients who agreed to help improve the assessment of Parkinson’s disease treatment by taking part in these trials; Parkinson’s UK for their funding; the UK Department of Health, whose core support for Birmingham Clinical Trials Unit made this review possible; and Alex Furmston, Kinga Malottki, Mohammad Tokhi, and Manijeh Ghods, who provided translations for foreign papers.

  • This paper is based on a Cochrane review by the same authors. Cochrane reviews are regularly updated as new evidence emerges and in response to comments and criticisms. This work has been undertaken to update the physiotherapy versus placebo or no intervention in Parkinson’s disease first published in 2001. The Cochrane Library should be consulted for the most recent version of the review.

  • Contributors: CEC, RS, CS, KW, and NI contributed to the design of the protocol. CLT, RS, LS, and CPH designed and implemented the searches. CLT, RS, CM, SP, and CPH selected the studies. CLT, SP, CM, and CPH undertook data extraction and assessment of risk of bias. CM, who throughout the review and analysis period was a research physiotherapist, provided expertise on technical aspects of the project as necessary. CLT, SP, NI, and CPH were involved in the data analysis. All authors were involved in interpretation of the review. NI is the study guarantor.

  • Funding: This review was funded by Parkinson’s UK and the UK Department of Health, which provided the University of Birmingham Clinical Trials Unit with core support.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: support from the Department of Health for the submitted work; CEC, RS, CS, KW, and NI had support from Parkinson’s UK; SP, CM, CEC, CS, KW, and NI are either recruiting to or involved in the running of the UK PD REHAB trial.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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