PMID- 36602886
OWN - NLM
STAT- MEDLINE
DCOM- 20230109
LR  - 20240229
IS  - 1469-493X (Electronic)
IS  - 1361-6137 (Linking)
VI  - 1
IP  - 1
DP  - 2023 Jan 5
TI  - Physical exercise for people with Parkinson's disease: a systematic review and 
      network meta-analysis.
PG  - CD013856
LID - 10.1002/14651858.CD013856.pub2 [doi]
LID - CD013856
AB  - BACKGROUND: Physical exercise is effective in managing Parkinson's disease (PD), 
      but the relative benefit of different exercise types remains unclear. OBJECTIVES: 
      To compare the effects of different types of physical exercise in adults with PD 
      on the severity of motor signs, quality of life (QoL), and the occurrence of 
      adverse events, and to generate a clinically meaningful treatment ranking using 
      network meta-analyses (NMAs). SEARCH METHODS: An experienced information 
      specialist performed a systematic search for relevant articles in CENTRAL, 
      MEDLINE, Embase, and five other databases to 17 May 2021. We also searched trial 
      registries, conference proceedings, and reference lists of identified studies up 
      to this date. SELECTION CRITERIA: We included randomized controlled trials (RCTs) 
      comparing one type of physical exercise for adults with PD to another type of 
      exercise, a control group, or both. DATA COLLECTION AND ANALYSIS: Two review 
      authors independently extracted data. A third author was involved in case of 
      disagreements.  We categorized the interventions and analyzed their effects on 
      the severity of motor signs, QoL, freezing of gait, and functional mobility and 
      balance up to six weeks after the intervention using NMAs. Two review authors 
      independently assessed the risk of bias using the risk of bias 2 (RoB 2) tool and 
      rated the confidence in the evidence using the CINeMA approach for results on the 
      severity of motor signs and QoL. We consulted a third review author to resolve 
      any disagreements. Due to heterogeneous reporting of adverse events, we 
      summarized safety data narratively and rated our confidence in the evidence using 
      the GRADE approach. MAIN RESULTS: We included 156 RCTs with a total of 7939 
      participants with mostly mild to moderate disease and no major cognitive 
      impairment. The number of participants per study was small (mean 51, range from 
      10 to 474). The NMAs on the severity of motor signs and QoL included data from 71 
      (3196 participants), and 55 (3283 participants) trials, respectively. Eighty-five 
      studies (5192 participants) provided safety data. Here, we present the main 
      results. We observed evidence of beneficial effects for most types of physical 
      exercise included in our review compared to a passive control group. The effects 
      on the severity of motor signs and QoL are expressed as scores on the motor scale 
      of the Unified Parkinson Disease Rating Scale (UPDRS-M) and the Parkinson's 
      Disease Questionnaire 39 (PDQ-39), respectively. For both scales, higher scores 
      denote higher symptom burden. Therefore, negative estimates reflect improvement 
      (minimum clinically important difference: -2.5 for UPDRS-M and -4.72 for PDQ-39). 
      Severity of motor signs The evidence from the NMA (71 studies; 3196 participants) 
      suggests that dance has a moderate beneficial effect on the severity of motor 
      signs (mean difference (MD) -10.32, 95% confidence interval (CI) -15.54 to -4.96; 
      high confidence), and aqua-based, gait/balance/functional, and multi-domain 
      training might have a moderate beneficial effect on the severity of motor signs 
      (aqua-based: MD -7.77, 95% CI -13.27 to -2.28; gait/balance/functional: MD -7.37, 
      95% CI -11.39 to -3.35; multi-domain: MD -6.97, 95% CI -10.32 to -3.62; low 
      confidence). The evidence also suggests that mind-body training and endurance 
      training might have a small beneficial effect on the severity of motor signs 
      (mind-body: MD -6.57, 95% CI -10.18 to -2.81; endurance: MD -6.43, 95% CI -10.72 
      to -2.28; low confidence). Flexibility training might have a trivial or no effect 
      on the severity of motor signs (MD 2.01, 95% CI -4.82 to 8.98; low confidence). 
      The evidence is very uncertain about the effects of strength/resistance training 
      and "Lee Silverman Voice training BIG" (LSVT BIG) on the severity of motor signs 
      (strength/resistance: MD -6.97, 95% CI -11.93 to -2.01; LSVT BIG: MD -5.49, 95% 
      CI -14.74 to 3.62; very low confidence). Quality of life The evidence from the 
      NMA (55 studies; 3283 participants) suggests that aqua-based training probably 
      has a large beneficial effect on QoL (MD -14.98, 95% CI -23.26 to -6.52; moderate 
      confidence). The evidence also suggests that endurance training might have a 
      moderate beneficial effect, and that gait/balance/functional and multi-domain 
      training might have a small beneficial effect on QoL (endurance: MD -9.16, 95% CI 
      -15.68 to -2.82; gait/balance/functional: MD -5.64, 95% CI -10.04 to -1.23; 
      multi-domain: MD -5.29, 95% CI -9.34 to -1.06; low confidence). The evidence is 
      very uncertain about the effects of mind-body training, gaming, 
      strength/resistance training, dance, LSVT BIG, and flexibility training on QoL 
      (mind-body: MD -8.81, 95% CI -14.62 to -3.00; gaming: MD -7.05, 95% CI -18.50 to 
      4.41; strength/resistance: MD -6.34, 95% CI -12.33 to -0.35; dance: MD -4.05, 95% 
      CI -11.28 to 3.00; LSVT BIG: MD 2.29, 95% CI -16.03 to 20.44; flexibility: MD 
      1.23, 95% CI -11.45 to 13.92; very low confidence). Adverse events Only 85 
      studies (5192 participants) provided some kind of safety data, mostly only for 
      the intervention groups. No adverse events (AEs) occurred in 40 studies and no 
      serious AEs occurred in four studies. AEs occurred in 28 studies. The most 
      frequently reported events were falls (18 studies) and pain (10 studies). The 
      evidence is very uncertain about the effect of physical exercise on the risk of 
      adverse events (very low confidence). Across outcomes, we observed little 
      evidence of differences between exercise types. AUTHORS' CONCLUSIONS: We found 
      evidence of beneficial effects on the severity of motor signs and QoL for most 
      types of physical exercise for people with PD included in this review, but little 
      evidence of differences between these interventions. Thus, our review highlights 
      the importance of physical exercise regarding our primary outcomes severity of 
      motor signs and QoL, while the exact exercise type might be secondary. Notably, 
      this conclusion is consistent with the possibility that specific motor symptoms 
      may be treated most effectively by PD-specific programs. Although the evidence is 
      very uncertain about the effect of exercise on the risk of adverse events, the 
      interventions included in our review were described as relatively safe. Larger, 
      well-conducted studies are needed to increase confidence in the evidence. 
      Additional studies recruiting people with advanced disease severity and cognitive 
      impairment might help extend the generalizability of our findings to a broader 
      range of people with PD.
CI  - Copyright (c) 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
FAU - Ernst, Moritz
AU  - Ernst M
AD  - Cochrane Haematology, Department I of Internal Medicine, Center for Integrated 
      Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Folkerts, Ann-Kristin
AU  - Folkerts AK
AD  - Medical Psychology, Neuropsychology and Gender Studies and Center for 
      Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and 
      University Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Gollan, Romina
AU  - Gollan R
AD  - Medical Psychology, Neuropsychology and Gender Studies and Center for 
      Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and 
      University Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Lieker, Emma
AU  - Lieker E
AD  - Medical Psychology, Neuropsychology and Gender Studies and Center for 
      Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and 
      University Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Caro-Valenzuela, Julia
AU  - Caro-Valenzuela J
AD  - Cochrane Haematology, Department I of Internal Medicine, Center for Integrated 
      Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Adams, Anne
AU  - Adams A
AD  - Institute of Medical Statistics and Computational Biology, Faculty of Medicine 
      and University Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Cryns, Nora
AU  - Cryns N
AD  - Cochrane Haematology, Department I of Internal Medicine, Center for Integrated 
      Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Monsef, Ina
AU  - Monsef I
AD  - Cochrane Haematology, Department I of Internal Medicine, Center for Integrated 
      Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Dresen, Antje
AU  - Dresen A
AD  - Institute of Medical Sociology, Health Services Resarch, and Rehabilitation 
      Science (IMVR), Faculty of Human Sciences and Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Roheger, Mandy
AU  - Roheger M
AD  - Ambulatory Assessment in Psychology, Department of Psychology, Carl von Ossietzky 
      University Oldenburg, Oldenburg, Germany.
FAU - Eggers, Carsten
AU  - Eggers C
AD  - Department of Neurology, University Hospital Marburg, Marburg, Germany.
AD  - Department of Neurology, Knappschaftskrankenhaus Bottrop GmbH, Bottrop, Germany.
FAU - Skoetz, Nicole
AU  - Skoetz N
AD  - Cochrane Haematology, Department I of Internal Medicine, Center for Integrated 
      Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University 
      Hospital Cologne, University of Cologne, Cologne, Germany.
FAU - Kalbe, Elke
AU  - Kalbe E
AD  - Medical Psychology, Neuropsychology and Gender Studies and Center for 
      Neuropsychological Diagnostics and Intervention (CeNDI), Faculty of Medicine and 
      University Hospital Cologne, University of Cologne, Cologne, Germany.
LA  - eng
SI  - ClinicalTrials.gov/NCT04012086
SI  - ClinicalTrials.gov/NCT02488265
SI  - ClinicalTrials.gov/NCT00750945
SI  - ClinicalTrials.gov/NCT03079817
SI  - ClinicalTrials.gov/NCT02509611
SI  - ClinicalTrials.gov/NCT00591344
SI  - ClinicalTrials.gov/NCT01388556
SI  - ClinicalTrials.gov/NCT02622737
SI  - ClinicalTrials.gov/NCT03213873
SI  - ClinicalTrials.gov/NCT00982709
SI  - ClinicalTrials.gov/NCT02231073
SI  - ClinicalTrials.gov/NCT02236286
SI  - ClinicalTrials.gov/NCT00611481
SI  - ClinicalTrials.gov/NCT04048291
SI  - ClinicalTrials.gov/NCT01701128
SI  - ClinicalTrials.gov/NCT02807740
SI  - ClinicalTrials.gov/NCT01120392
SI  - ClinicalTrials.gov/NCT02999997
SI  - ClinicalTrials.gov/NCT01573260
SI  - ClinicalTrials.gov/NCT02966600
SI  - ClinicalTrials.gov/NCT03235284
SI  - ClinicalTrials.gov/NCT01257945
SI  - ClinicalTrials.gov/NCT01506479
SI  - ClinicalTrials.gov/NCT02253563
SI  - ClinicalTrials.gov/NCT01939717
SI  - ClinicalTrials.gov/NCT02302144
SI  - ClinicalTrials.gov/NCT03193268
SI  - ClinicalTrials.gov/NCT03189680
SI  - ClinicalTrials.gov/NCT02902510
SI  - ClinicalTrials.gov/NCT02418780
SI  - ClinicalTrials.gov/NCT01799681
SI  - ClinicalTrials.gov/NCT01301651
SI  - ClinicalTrials.gov/NCT03689764
SI  - ClinicalTrials.gov/NCT03882398
SI  - ClinicalTrials.gov/NCT03463330
SI  - ClinicalTrials.gov/NCT03637023
SI  - ClinicalTrials.gov/NCT04291027
SI  - ClinicalTrials.gov/NCT02593955
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SI  - ClinicalTrials.gov/NCT00004760
SI  - ClinicalTrials.gov/NCT00029809
SI  - ClinicalTrials.gov/NCT00167453
SI  - ClinicalTrials.gov/NCT00387218
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SI  - ClinicalTrials.gov/NCT01246700
SI  - ClinicalTrials.gov/NCT01427062
SI  - ClinicalTrials.gov/NCT01439022
SI  - ClinicalTrials.gov/NCT01562496
SI  - ClinicalTrials.gov/NCT01757509
SI  - ClinicalTrials.gov/NCT01835652
SI  - ClinicalTrials.gov/NCT01960985
SI  - ClinicalTrials.gov/NCT02017938
SI  - ClinicalTrials.gov/NCT02267785
SI  - ClinicalTrials.gov/NCT02419768
SI  - ClinicalTrials.gov/NCT02476240
SI  - ClinicalTrials.gov/NCT02476266
SI  - ClinicalTrials.gov/NCT02615548
SI  - ClinicalTrials.gov/NCT02656355
SI  - ClinicalTrials.gov/NCT02674724
SI  - ClinicalTrials.gov/NCT02745171
SI  - ClinicalTrials.gov/NCT02816619
SI  - ClinicalTrials.gov/NCT03212014
SI  - ClinicalTrials.gov/NCT03406728
SI  - ClinicalTrials.gov/NCT03443752
SI  - ClinicalTrials.gov/NCT03568903
SI  - ClinicalTrials.gov/NCT03618901
SI  - ClinicalTrials.gov/NCT01636297
SI  - ClinicalTrials.gov/NCT02457832
SI  - ClinicalTrials.gov/NCT03244813
SI  - ClinicalTrials.gov/NCT03343574
SI  - ClinicalTrials.gov/NCT03560089
SI  - ClinicalTrials.gov/NCT03563807
SI  - ClinicalTrials.gov/NCT03582371
SI  - ClinicalTrials.gov/NCT03711955
SI  - ClinicalTrials.gov/NCT03751371
SI  - ClinicalTrials.gov/NCT02885285
SI  - ClinicalTrials.gov/NCT03833349
SI  - ClinicalTrials.gov/NCT03860649
SI  - ClinicalTrials.gov/NCT03882879
SI  - ClinicalTrials.gov/NCT03960931
SI  - ClinicalTrials.gov/NCT03972969
SI  - ClinicalTrials.gov/NCT03974529
SI  - ClinicalTrials.gov/NCT03983785
SI  - ClinicalTrials.gov/NCT04000360
SI  - ClinicalTrials.gov/NCT04046276
SI  - ClinicalTrials.gov/NCT04063605
SI  - ClinicalTrials.gov/NCT04122690
SI  - ClinicalTrials.gov/NCT04135924
SI  - ClinicalTrials.gov/NCT04194762
SI  - ClinicalTrials.gov/NCT04215900
SI  - ClinicalTrials.gov/NCT04379778
SI  - ClinicalTrials.gov/NCT04558879
SI  - ClinicalTrials.gov/NCT04613141
SI  - ClinicalTrials.gov/NCT04644367
SI  - ClinicalTrials.gov/NCT04665869
SI  - ClinicalTrials.gov/NCT04699617
SI  - ClinicalTrials.gov/NCT04863118
SI  - ClinicalTrials.gov/NCT04872153
SI  - ClinicalTrials.gov/NCT04878679
PT  - Journal Article
PT  - Meta-Analysis
PT  - Research Support, Non-U.S. Gov't
PT  - Review
PT  - Systematic Review
DEP - 20230105
PL  - England
TA  - Cochrane Database Syst Rev
JT  - The Cochrane database of systematic reviews
JID - 100909747
SB  - IM
UOF - doi: 10.1002/14651858.CD013856
MH  - Adult
MH  - Humans
MH  - *Parkinson Disease/therapy
MH  - Network Meta-Analysis
MH  - Exercise
MH  - Gait
MH  - *Resistance Training
MH  - Quality of Life
PMC - PMC9815433
COIS- ME is associated with the Cochrane Haematology group, but was not involved in the 
      editorial process of this review.
AF has been involved in an ongoing study 
      eligible for inclusion (Goosses 2020). She was not involved in the assessment of 
      the study's eligibility and she will not be involved in the data extraction or 
      the assessment of risk of bias in the future.
RG: none known
EL: none known
JCV 
      is associated with the Cochrane Haematology group, but was not involved in the 
      editorial process of this review.
NC is associated with the Cochrane Haematology 
      group, but was not involved in the editorial process of this review.
AA is 
      associated with the Cochrane Haematology group, but was not involved in the 
      editorial process of this review.
IM is associated with the Cochrane Haematology 
      group, but was not involved in the editorial process of this review.
AD: none 
      known
MR: none known
CE: none known
NS is associated with the Cochrane 
      Haematology group, but was not involved in the editorial process of this 
      review.
EK has been involved in an ongoing study eligible for inclusion (Goosses 
      2020). She was not involved in the assessment of the study's eligibility and she 
      will not be involved in the data extraction or the assessment of risk of bias in 
      the future.
EDAT- 2023/01/06 06:00
MHDA- 2023/01/10 06:00
PMCR- 2024/01/05
CRDT- 2023/01/05 12:12
PHST- 2023/01/05 12:12 [entrez]
PHST- 2023/01/06 06:00 [pubmed]
PHST- 2023/01/10 06:00 [medline]
PHST- 2024/01/05 00:00 [pmc-release]
AID - CD013856.pub2 [pii]
AID - 10.1002/14651858.CD013856.pub2 [doi]
PST - epublish
SO  - Cochrane Database Syst Rev. 2023 Jan 5;1(1):CD013856. doi: 
      10.1002/14651858.CD013856.pub2.