Effectiveness of Long-Term Physiotherapy in Parkinson's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Long-term physiotherapy is acknowledged to be crucial to manage motor symptoms for Parkinson's disease (PD) patients, but its effectiveness is not well understood. OBJECTIVE: This systematic review and meta-analysis aimed to assess the evidence regarding the effectiveness of long-term physiotherapy to improve motor symptoms and reduce antiparkinsonian medication dose in PD patients. METHODS: Pubmed, Cochrane, PEDro, and CINAHL were searched for randomized controlled trials before August 31, 2020 that investigated the effectiveness of physiotherapy for 6 months or longer on motor symptoms and levodopa-equivalent dose (LED) in PD patients with Hoehn and Yahr stage 1- 3. We performed random effects meta-analyses for long-term physiotherapy versus no/control intervention and estimated standard mean differences with 95% confidence intervals (CIs). Levels of evidence were rated by the Grading of Recommendation Assessment, Development and Evaluation approach. RESULTS: From 2,940 studies, 10 studies involving 663 PD patients were assessed. Long-term physiotherapy had favorable effects on motor symptoms in off medication state [- 0.65, 95% CI - 1.04 to - 0.26, p = 0.001] and LED [- 0.49, 95% CI - 0.89to - 0.09, p = 0.02]. Subgroup analyses demonstrated favorable effects on motor symptoms in off medication state by aerobic exercise [- 0.42, 95% CI - 0.64 to - 0.20, p < 0.001] and LED by multidisciplinary rehabilitation of primarily physiotherapy [- 1.00, 95% CI - 1.44 to - 0.56, p < 0.001]. Quality of evidence for aerobic exercise and multidisciplinary rehabilitation were low and very low. CONCLUSION: This review provided evidence that long-term physiotherapy has beneficial impact on motor symptoms and antiparkinsonian medication dose in PD patients and could motivate implementation of long-term physiotherapy.

Tonic suppression of the soleus H-reflex during rhythmic movement of the contralateral ankle.

[Purpose] We investigated the effect of rhythmic ankle movement on the contralateral soleus H-reflex. The H-reflex was evoked from the right soleus muscle. [Subjects and Methods] Healthy humans rhythmically moved the left ankle (movement condition) or held the left ankle stationary (stationary condition) at one of three positions corresponding to the ankle positions at which the H-reflex was evoked in the movement condition. The background electromyographic amplitude in the right soleus muscle was maintained at 10% of the maximum voluntary contraction level, and that in the right tibialis anterior muscle was matched between the stationary and movement conditions. [Results] The soleus H-reflex was suppressed throughout all phases of contralateral rhythmic ankle movement. [Conclusion] Rhythmic movement of the contralateral joint suppresses the H-reflex in the muscle that is the prime mover of the joint homologous to the rhythmically moving joint. This inhibitory mechanism may be activated during unilateral rhythmic movement to isolate the motor control of the moving ankle from that of the contralateral stationary ankle.

Effect of cerebellar transcranial magnetic stimulation on soleus Ia presynaptic and reciprocal inhibition.

Previously, we reported that cerebellar transcranial magnetic stimulation (C-TMS) facilitates spinal motoneuronal excitability in resting humans. In this study, we aimed to characterize the descending pathway that is responsible for the C-TMS-associated cerebellar spinal facilitation. We evaluated the effect of C-TMS on ipsilateral soleus Ia presynaptic inhibition (PSI) and reciprocal inhibition (RI) because the vestibulospinal and reticulospinal tracts project from the cerebellum to mediate spinal motoneurons via interneurons associated with PSI. PSI and RI were measured with a soleus H-reflex test following operant conditioning using electrical stimulation of the common peroneal nerve. C-TMS was delivered before test tibial nerve stimulation with conditioning-test interstimulus intervals of 110 ms. C-TMS did not generate motor-evoked potentials, and it did not increase electromyography activity in the ipsilateral soleus muscle, indicating that C-TMS does not directly activate the corticospinal tract and motoneurons. However, C-TMS facilitated the ipsilateral soleus H-reflex and reduced the amount of soleus Ia PSI, but not RI. These findings indicate that C-TMS may facilitate the excitability of the spinal motoneuron pool via the vestibulospinal or reticulospinal tracts associated with PSI. Cerebellar spinal facilitation may be useful for assessing the functional connectivity of the cerebellum and vestibular nuclei or reticular formation.

Task dependency of the long-latency facilitatory effect on the soleus H-reflex by cerebellar transcranial magnetic stimulation.

We investigated whether cerebellar transcranial magnetic stimulation (C-TMS) facilitates the excitability of the ipsilateral soleus motoneuron pool in resting humans, and whether the facilitation is modulated by a task that promotes cerebellar activity. A test tibial nerve stimulus evoking the H-reflex from the right soleus muscle was delivered before or after conditioning C-TMS in prone individuals. The amplitude of the H-reflex was significantly increased at conditioning-test interstimulus intervals of 110, 120, and 130 ms. Furthermore, we revealed that this facilitation effect was inhibited while the individuals tapped their right index finger. These findings indicate that C-TMS facilitates spinal motoneuronal excitability with an ∼100 ms latency in resting humans, and that this cerebellar spinal facilitation is modulated by a task that might increase cerebellar activity. Cerebellar spinal facilitation could thus be useful for assessing the excitability of the cerebellum, or the cerebellar output to spinal motoneurons.

The effect of eye movement on the control of arm movement to a target.

The purpose of this study was to investigate the effect of eye movement on the control of arm movement to a target. Healthy humans flexed the elbow to a stationary target in response to a start tone. Simultaneously, the subject moved the eyes to the target (saccade eye movement), visually tracked a laser point moving with the arm (smooth pursuit eye movement), or gazed at a stationary start point at the midline of the horizontal visual angle (non-eye movement--NEM). Arm movement onset was delayed when saccade eye movement accompanied it. The onset of an electromyographic burst in the biceps muscle and the onset of saccade eye movement were almost simultaneous when both the arm and the eyes moved to the target. Arm movement duration during smooth pursuit eye movement was significantly longer than that during saccade eye movement or NEM. In spite of these findings, amplitudes of motor-evoked potential in the biceps and triceps brachii muscles were not significantly different among the eye movement conditions. These findings indicate that eye movement certainly affects the temporal control of arm movement, but may not affect corticospinal excitability in the arm muscles during arm movement.

The effect of advance information about the sequence of a to-be-signaled motor response on corticospinal excitability during the foreperiod.

We investigated the effect of advance information about the sequence of a to-be-signaled motor response on corticospinal excitability during the foreperiod in healthy humans. Advance information about the sequence of a to-be-signaled motor response was provided by a precue signal 600 ms before a response signal during a warned choice reaction task. The precue signal indicated the sequence of one of three to-be-signaled motor responses: simple, repetitive, or sequential motor responses. The amplitude of the motor-evoked potential (MEP) decreased significantly 100 ms before the response signal in both the first dorsal interosseous (FDI) and abductor pollicis brevis (APB) muscles, but a significant decrease was present only in the APB muscle 300 ms before the response signal. The decrease in the MEP amplitude 100 ms before the response signal induced by the precue signal indicating the repetitive motor response was significantly smaller than that induced by the precue signal indicating the simple or sequential motor response in the FDI muscle, and was significantly smaller than that induced by the precue signal indicating the sequential motor response in the APB muscle. The decrease in corticospinal excitability in the middle foreperiod is larger when the advance information about a to-be-signaled motor response is unrelated to the muscle tested, and the decrease in the late foreperiod is affected by advance information about the sequence of a to-be-signaled motor response.

Long latency fluctuation of the finger movement evoked by cerebellar TMS during visually guided manual tracking task.

The purpose of this study was to investigate whether right index finger movement during visually guided manual tracking task is fluctuated by transcranial magnetic stimulation (TMS) specifically over the cerebellum and is differently fluctuated by TMS over different sites of the cerebellum. TMS was delivered over the left, middle, or right cerebellum, or Pz. Index finger movement and electromyographic response in the first dorsal interosseous were recorded. Fluctuation of the finger movement appeared approximately 100 ms after cerebellar TMS with a probability of approximately 20%. The probability was significantly higher than that after TMS over the Pz or that after sham TMS. The probability was not significantly different among different TMS sites over the cerebellum. The long latency fluctuation of the finger movement during visually guided manual tracking task is evoked by TMS specifically over the cerebellum, but is not preferentially evoked by a specific site of the cerebellum. Cerebellar TMS induced long latency motor response may be useful to investigate the neural pathways activated by TMS over the cerebellum.

Premovement facilitation of corticospinal excitability before simple and sequential movement.

The purpose of this study was to investigate whether premovement facilitation of corticospinal excitability before sequential movement was different from that before simple movement. Each of 7 participants who performed choice reaction tasks with the right hand pressed a force transducer with the index finger in response to a start cue or pressed the transducers sequentially with the index finger, little finger, thumb, little finger, and index finger. Transcranial magnetic stimulation was delivered to the left motor cortex before the electromyographic burst in the first dorsal interosseous muscle and motor evoked potentials were recorded from the first dorsal interosseous muscle. The amplitude of the motor-evoked potential increased as its onset got closer to the onset of the electromyographic burst. The increase before the sequential movement was larger and began earlier than that before the simple movement. These findings indicate that premovement facilitation of corticospinal excitability is different in magnitude and timing between sequential and simple movements.

Overestimation of stability limits leads to a high frequency of falls in patients with Parkinson's disease.

OBJECTIVES: To test a hypothesis that patients with Parkinson's disease may not notice discrepancies between their perceived and actual stability limits and cannot keep their centre of gravity within the stability region. SETTINGS: Outpatients with neurological disorders in rehabilitation service. SUBJECTS: Twenty-one patients with Parkinson's disease (11 men, 10 women; mean duration 5.9 +/- 3.9 years) and age- and sex-matched healthy volunteers were recruited. METHODS: Each subject's right arm length was subtracted from the distance between the right acromion and the perceived reachable boundary. This was called 'perceived reach'. The figure given by subtracting the right arm length from the maximum forward reach length measured by the Functional Reach Test was named 'actual reach', and is an index of actual stability limits in each subject. The difference between actual and perceived stability limits (DAP) is given by actual reach minus perceived reach. The motor score of the Unified Parkinson's Disease Rating Scale were used to evaluate disease severity. RESULTS: The mean DAP for the Parkinson's disease group was negative (-1.8 +/- 5.7 cm) and significantly different from that of controls (3.3 +/- 9.2 cm) (P < 0.05). In Parkinson's disease, DAP was significantly correlated with the Unified Parkinson's Disease Rating Scale score (correlation coefficient = -0.39, P < 0.05). CONCLUSIONS: These results indicated that patients with Parkinson's disease overestimated their stability limits, which may result in falls. In addition, the results demonstrate that patients with Parkinson's disease develop overestimation of stability limits in parallel with their disease progression.