title: Exercise for falls prevention in Parkinson disease The PIT: SToPP Trial—A Feasibility Randomised Controlled Trial of Home-Based Physiotherapy for People with Parkinson's Disease Using Video-Based Measures to Preserve Assessor Blinding Home-based step training using videogame technology in people with Parkinson’s disease: a single-blinded randomised controlled trial Balance training in individuals with Parkinson's disease: Therapist-supervised vs. home-based exercise programme. A home program of strength training, movement strategy training and education did not prevent falls in people with Parkinson's disease: a randomised trial. Virtual Reality Telerehabilitation for Postural Instability in Parkinson's Disease: A Multicenter, Single-Blind, Randomized, Controlled Trial Home-based treadmill training for individuals with Parkinson’s disease: a randomized controlled pilot trial Minimal Detectable Change of the Timed “Up & Go” Test and the Dynamic Gait Index in People With Parkinson Disease Comparison of the effects of a physiotherapist-supervised exercise programme and a self-supervised exercise programme on quality of life in patients with Parkinson’s disease An exercise intervention to prevent falls in Parkinson’s: an economic evaluation The effects of an exercise program on fall risk factors in people with Parkinson's disease: a randomized controlled trial. Exercise and Motor Training in People with Parkinson's Disease: A Systematic Review of Participant Characteristics, Intervention Delivery, Retention Rates, Adherence, and Adverse Events in Clinical Trials The Effects of Highly Challenging Balance Training in Elderly With Parkinson’s Disease Effects of home exercises on motor performance in patients with Parkinson's disease Reliability of measurements obtained with the Timed "Up & Go" test in people with Parkinson disease. Comparison of Reliability, Validity, and Responsiveness of the Mini-BESTest and Berg Balance Scale in Patients With Balance Disorders Validating the Berg Balance Scale for patients with Parkinson's disease: a key to rehabilitation evaluation. Reliability of the PEDro scale for rating quality of randomized controlled trials. A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson’s disease A Randomized Controlled Trial to Reduce Falls in People With Parkinson’s Disease Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial Effects of Group, Individual, and Home Exercise in Persons With Parkinson Disease: A Randomized Clinical Trial An exercise intervention to prevent falls in people with Parkinson's disease: a pragmatic randomised controlled trial A pilot study of a minimally supervised home exercise and walking program for people with Parkinson's disease in Jordan. Long-term effects of highly challenging balance training in Parkinson’s disease—a randomized controlled trial Early predictors of mortality in parkinsonism and Parkinson disease Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson’s
abstract: Objective : To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors , i.e. , poor balance , reduced leg muscle strength , and freezing of gait , in people with Parkinson disease . Methods : Two hundred thirty-one people with Parkinson disease were r and omized into exercise or usual-care control groups . Exercises were practice d for 40 to 60 minutes , 3 times weekly for 6 months . Primary outcomes were fall rates and proportion of fallers during the intervention period . Secondary outcomes were physical ( balance , mobility , freezing of gait , habitual physical activity ) , psychological ( fear of falling , affect ) , and quality -of-life measures . Results : There was no significant difference between groups in the rate of falls ( incidence rate ratio [ IRR ] = 0.73 , 95 % confidence interval [ CI ] 0.45–1.17 , p = 0.18 ) or proportion of fallers ( p = 0.45 ) . Preplanned subgroup analysis revealed a significant interaction for disease severity ( p < 0.001 ) . In the lower disease severity subgroup , there were fewer falls in the exercise group compared with controls ( IRR = 0.31 , 95 % CI 0.15–0.62 , p < 0.001 ) , while in the higher disease severity subgroup , there was a trend toward more falls in the exercise group ( IRR = 1.61 , 95 % CI 0.86–3.03 , p = 0.13 ) . Postintervention , the exercise group scored significantly ( p < 0.05 ) better than controls on the Short Physical Performance Battery , sit-to-st and , fear of falling , affect , and quality of life , after adjusting for baseline performance . Conclusions : An exercise program targeting balance , leg strength , and freezing of gait did not reduce falls but improved physical and psychological health . Falls were reduced in people with milder disease but not in those with more severe Parkinson disease . Classification of evidence : This study provides Class III evidence that for patients with Parkinson disease , a minimally supervised exercise program does not reduce fall risk . This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise . Trial registration : Australian New Zeal and Clinical Trials Registry ( ACTRN12608000303347 ) Purpose . To trial four-week 's physiotherapy targeting chair transfers for people with Parkinson 's disease ( PwPD ) and explore the feasibility of reliance on remote outcome measurement to preserve blinding . Scope . We recruited 47 PwPD and r and omised 24 to a focused home physiotherapy programme ( exercise , movement strategies , and cueing ) and 23 to a control group . We evaluated transfers ( plus mobility , balance , posture , and quality of life ) before and after treatment and at followup ( weeks 0 , 4 , 8 , and 12 ) from video produced by , and question naires distributed by , treating physiotherapists . Participants fed back via end-of- study question naires . Thirty-five participants ( 74 % ) completed the trial . Excluding dropouts , 20 % of question naire data and 9 % of video data were missing or unusable ; we had to evaluate balance in situ . We noted trends to improvement in transfers , mobility , and balance in the physiotherapy group not noted in the control group . Participant feedback was largely positive and assessor blinding was maintained in every case . Conclusions . Intense , focused physiotherapy at home appears acceptable and likely to bring positive change in those who can participate . Remote outcome measurement was successful ; question naire followup and further training in video production would reduce missing data . We advocate a fully powered trial , design ed to minimise dropouts and preserve assessor blinding , to evaluate this intervention Objectives : To determine whether 12-week home-based exergame step training can improve stepping performance , gait and complementary physical and neuropsychological measures associated with falls in Parkinson ’s disease . Design : A single-blinded r and omised controlled trial . Setting : Community ( experimental intervention ) , university laboratory ( outcome measures ) . Subjects : Sixty community-dwelling people with Parkinson ’s disease . Interventions : Home-based step training using videogame technology . Main measures : The primary outcomes were the choice stepping reaction time test and Functional Gait Assessment . Secondary outcomes included physical and neuropsychological measures associated with falls in Parkinson ’s disease , number of falls over six months and self-reported mobility and balance . Results : Post intervention , there were no differences between the intervention ( n = 28 ) and control ( n = 25 ) groups in the primary or secondary outcomes except for the Timed Up and Go test , where there was a significant difference in favour of the control group ( P = 0.02 ) . Intervention participants reported mobility improvement , whereas control participants reported mobility deterioration — between-group difference on an 11-point scale = 0.9 ( 95 % confidence interval : −1.8 to −0.1 , P = 0.03 ) . Interaction effects between intervention and disease severity on physical function measures were observed ( P = 0.01 to P = 0.08 ) with seemingly positive effects for the low-severity group and potentially negative effects for the high-severity group . Conclusion : Overall , home-based exergame step training was not effective in improving the outcomes assessed . However , the improved physical function in the lower disease severity intervention participants as well as the self-reported improved mobility in the intervention group suggest home-based exergame step training may have benefits for some people with Parkinson ’s disease BACKGROUND Poor locomotion and balance in Parkinson 's disease ( PD ) often diminishes independence . Accordingly , gait is considered one of the most relevant rehabilitation outcomes , and home-based balance exercises might be a viable mode of exercise delivery for individuals with PD . However , research on PD interventions rarely indicate best practice s to deliver exercises . Therefore , this study endeavoured to compare the efficacy of a home-based and therapist-supervised balance programme on gait parameters , dynamic balance , balance confidence and motivation in individuals diagnosed with PD . METHODS An experimental study design , including a cluster r and omized convenience sample , of 40 participants with idiopathic PD ( Hoehn and Yahr stage I-III ; age : 65.0±7.7years ) . Participants were divided into a therapist-supervised ( n=24 ) and home-based group ( n=16 ) . Groups received either eight weeks of balance training with an exercise therapist or a DVD . Outcome measures include the instrumented Timed-Up- and -Go , Functional Gait Analysis ( FGA ) , Activity-specific Balance confidence ( ABC ) scale and Intrinsic Motivation Inventory ( IMI ) . RESULTS Both groups improved in stride length ( p<0.05 ) . Similar FGA improved by 9 % and 16 % in the therapist-supervised and home-based group , respectively ( p<0.01 ) . Only the therapist-supervised group showed improvements in ABC ( p=0.051 ) , stride velocity ( p=0.0006 ) and cadence ( p=0.046 ) over the intervention ; the latter two were also better compared to home-based ( p<0.05 ) . Furthermore the therapist-supervised group were more motivated ( p=002 ) . CONCLUSION The home-based balance programme was effective in improving some aspects of gait , albeit the programme supervised by an exercise therapist included somewhat more benefits after the intervention i.e. stride velocity and cadence in individuals with mild to moderate PD QUESTIONS For people with idiopathic Parkinson 's disease , does a 6-week , comprehensive , home exercise program reduce falls and disability and improve health-related quality of life ? Is the program cost-effective ? DESIGN R and omised , controlled trial with concealed allocation and assessor blinding . PARTICIPANTS One hundred and thirty-three community-dwelling adults with Parkinson 's disease . INTERVENTION The experimental group completed a 6-week home program comprising progressive resistance strength training , movement strategy training and falls education . The control group completed 6 weeks of non-specific life skills training . Participants in both groups received weekly therapist-guided sessions for 6 consecutive weeks and a weekly self-directed home program . OUTCOME MEASURES The primary outcome was the rate of falls , documented for the 12-month period immediately after therapy . Secondary outcomes were disability and health-related quality of life , assessed before and after intervention and at a 12-month follow-up . RESULTS A total of 2255 falls were reported by the 12-month follow-up . The proportion of fallers in the experimental and control groups was 61 and 72 % , respectively , which was not statistically significantly different ( RR=0.85 , 95 % CI 0.66 to 1.09 ) . There was no significant between-group difference in the rate of falls ( incidence rate ratio=1.58 , 95 % CI 0.73 to 3.43 ) . A survival analysis of participant time to first fall did not show a significant between-group difference ( log-rank test χ2=0.79 , p=0.37 ) . No significant between-group differences occurred for mobility , disability or quality of life . The mean cost of delivering the experimental intervention was AUD1596 . CONCLUSION A home program of strength and movement strategy training and falls education does not prevent falls when applied at the dose used in this study . Arguably , the dosage of therapy was insufficient . Future trials need to explore further therapy content , repetitions and duration , in order to optimise outcomes and cost-effectiveness . [ Morris ME , Taylor NF , Watts JJ , Evans A , Horne M , Kempster P , Danoudis M , McGinley J , Martin C , Menz HB ( 2017 ) A home program of strength training , movement strategy training and education did not prevent falls in people with Parkinson 's disease : a r and omised trial . Journal of Physiotherapy 63 : 94 - 100 ] Introduction Telerehabilitation enables patients to access remote rehabilitation services for patient-physiotherapist videoconferencing in their own homes . Home-based virtual reality ( VR ) balance training has been shown to reduce postural instability in patients with Parkinson 's disease ( PD ) . The primary aim was to compare improvements in postural stability after remotely supervised in-home VR balance training and in-clinic sensory integration balance training ( SIBT ) . Methods In this multicenter study , 76 PD patients ( modified Hoehn and Yahr stages 2.5–3 ) were r and omly assigned to receive either in-home VR telerehabilitation ( n = 38 ) or in-clinic SIBT ( n = 38 ) in 21 sessions of 50 minutes each , 3 days/week for 7 consecutive weeks . VR telerehabilitation consisted of grade d exergames using the Nintendo Wii Fit system ; SIBT included exercises to improve postural stability . Patients were evaluated before treatment , after treatment , and at 1-month follow-up . Results Analysis revealed significant between-group differences in improvement on the Berg Balance Scale for the VR telerehabilitation group ( p = 0.04 ) and significant Time × Group interactions in the Dynamic Gait Index ( p = 0.04 ) for the in-clinic group . Both groups showed differences in all outcome measures over time , except for fall frequency . Cost comparison yielded between-group differences in treatment and equipment costs . Conclusions VR is a feasible alternative to in-clinic SIBT for reducing postural instability in PD patients having a caregiver Objective : To investigate the feasibility and effectiveness of six weeks of home-based treadmill training in people with mild Parkinson ’s disease . Design : Pilot r and omized controlled trial of a six-week intervention followed by a further six weeks follow-up . Setting : Home-based treadmill training with outcome measures taken at a hospital clinic . Participants : Twenty cognitively intact participants with mild Parkinson ’s disease and gait disturbance . Two participants from the treadmill training group and one from the control group dropped out . Interventions : The treadmill training group undertook a semi-supervised home-based programme of treadmill walking for 20–40 minutes , four times a week for six weeks . The control group received usual care . Main outcome measures : The feasibility of the intervention was assessed by recording exercise adherence and acceptability , exercise intensity , fatigue , muscle soreness and adverse events . The primary outcome measure of efficacy was walking capacity ( 6-minute walk test distance ) . Results : Home-based treadmill training was feasible , acceptable and safe with participants completing 78 % ( SD 36 ) of the prescribed training sessions . The treadmill training group did not improve their walking capacity compared to the control group . The treadmill training group showed a greater improvement than the control group in fatigue at post test ( P = 0.04 ) and in quality of life at six weeks follow-up testing ( P = 0.02 ) . Conclusions : Semi-supervised home-based treadmill training is a feasible and safe form of exercise for cognitively intact people with mild Parkinson ’s disease . Further investigation regarding the effectiveness of home-based treadmill training is warranted Background The minimal detectable change ( MDC ) is the smallest amount of difference in individual scores that represents true change ( beyond r and om measurement error ) . The MDCs of the Timed “ Up & Go ” Test ( TUG ) and the Dynamic Gait Index ( DGI ) in people with Parkinson disease ( PD ) are largely unknown , limiting the interpretability of the change scores of both measures . Objective The purpose of this study was to estimate the MDCs of the TUG and the DGI in people with PD . Design This investigation was a prospect i ve cohort study . Methods Seventy-two participants were recruited from special clinics for movement disorders at a university hospital . Their mean age was 67.5 years , and 61 % were men . All participants completed the TUG and the DGI assessment s twice , about 14 days apart . The MDC was calculated from the st and ard error of measurement . The percentage MDC ( MDC% ) was calculated as the MDC divided by the mean of all scores for the sample . Furthermore , the intraclass correlation coefficient was used to examine the reproducibility between testing sessions ( test-retest reliability ) . Results The respective MDC and MDC% of the TUG were 3.5 seconds and 29.8 , and those of the DGI were 2.9 points and 13.3 . The test-retest reliability values for the TUG and the DGI were high ; the intraclass correlation coefficients were .80 and .84 , respectively . Limitations The study sample was a convenience sample , and the participants had mild to moderately severe PD . Conclusions The results showed that the TUG and the DGI have generally acceptable r and om measurement error and test-retest reliability . These findings should help clinicians and research ers determine whether a change in an individual patient with PD is a true change Objectives : To compare the effects of a physiotherapist-supervised exercise programme in an exercise unit and self-supervised home exercise programme on quality of life in patients with Parkinson ’s disease . Design : Assessor-blinded , quasi-r and omized trial ( alternate allocation ) . Setting : An outpatient exercise unit ; home setting s. Participants : Thirty patients with idiopathic Parkinson ’s disease , Hoehn & Yahr I — III , stable medication use . Interventions : Patients were included in the physiotherapist-supervised or home group . The exercise programme was performed for 10 weeks , three times/week either under the supervision of a physiotherapist or at home without supervision . Main outcome measures : Parkinson ’s Disease Quality of Life Question naire ( PDQLQ ) , Nottingham Health Profile ( NHP ) , Unified Parkinson ’s Disease Rating Scale ( UPDRS ) , Beck Depression Inventory ( BDI ) . Results : Patients in the supervised physiotherapy group improved more than the home exercise group in Parkinson ’s Disease Quality of Life Question naire ( total score , Parkinson ’s symptoms , emotional function ) , Nottingham Health Profile total , Unified Parkinson ’s Disease Rating Scale ( all domains ) and Beck Depression Inventory scores . Conclusions : The exercise programme under physiotherapist supervision was found to be more effective at improving activities of daily living , motor , mental , emotional functions and general health quality in patients with Parkinson ’s disease compared with a self-supervised home programme Background People with Parkinson ’s ( PwP ) experience frequent and recurrent falls . As these falls may have devastating consequences , there is an urgent need to identify cost-effective interventions with the potential to reduce falls in PwP. The purpose of this economic evaluation is to compare the costs and cost-effectiveness of a targeted exercise programme versus usual care for PwP who were at risk of falling . Methods One hundred and thirty participants were recruited through specialist clinics , primary care and Parkinson ’s support groups and r and omised to either an exercise intervention or usual care .  Health and social care utilisation and health-related quality of life ( EQ-5D ) were assessed over the 20 weeks of the study ( ten-week intervention period and ten-week follow up period ) , and these data were complete for 93 participants . Incremental cost per quality adjusted life year ( QALY ) was estimated . The uncertainty around costs and QALYs was represented using cost-effectiveness acceptability curves . Results The mean cost of the intervention was £ 76 per participant . Although in direction of favour of exercise intervention , there was no statistically significant differences between groups in total healthcare ( −£128 , 95 % CI : -734 to 478 ) , combined health and social care costs ( £ -35 , 95 % CI : -817 to 746 ) or QALYs ( 0.03 , 95 % CI : -0.02 to 0.03 ) at 20 weeks . Nevertheless , exploration of the uncertainty surrounding these estimates suggests there is more than 80 % probability that the exercise intervention is a cost-effective strategy relative to usual care . Conclusion Whilst we found no difference between groups in total healthcare , total social care cost and QALYs , analyses indicate that there is high probability that the exercise intervention  is cost-effective compared with usual care . These results require confirmation by larger trial-based economic evaluations and over the longer term This r and omized controlled trial with blinded assessment aim ed to determine the effect of a 6-month minimally supervised exercise program on fall risk factors in people with Parkinson 's disease ( PD ) . Forty-eight participants with PD who had fallen or were at risk of falling were r and omized into exercise or control groups . The exercise group attended a monthly exercise class and exercised at home three times weekly . The intervention targeted leg muscle strength , balance , and freezing . The primary outcome measure was a PD falls risk score . The exercise group had no major adverse events and showed a greater improvement than the control group in the falls risk score , which was not statistically significant ( between group mean difference = -7 % , 95 % CI -20 to 5 , P = 0.26 ) . There were statistically significant improvements in the exercise group compared with the control group for two secondary outcomes : Freezing of Gait Question naire ( P = 0.03 ) and timed sit-to-st and ( P = 0.03 ) . There were statistically nonsignificant trends toward greater improvements in the exercise group for measures of muscle strength , walking , and fear of falling , but not for the measures of st and ing balance . Further investigation of the impact of exercise on falls in people with PD is warranted There is research evidence that exercise and motor training are beneficial for people with Parkinson 's disease ( PD ) , and clinicians seek to implement optimal programs . This paper summarizes important factors about the nature and reporting of r and omized controlled trials of exercise and /or motor training for people with PD which are likely to influence the translation of research into clinical practice . Search es identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 ( SD 4.2 ) weeks . Most interventions were fully supervised ( 74 % ) and conducted at a facility ( 79 % ) . Retention rates were high with 69 % of interventions retaining ≥85 % of their participants ; however adherence was infrequently reported , and 72 % of trials did not report adverse events . Overall , the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocol s that translate to sustainable clinical practice for people with PD Background . Highly challenging exercises have been suggested to induce neuroplasticity in individuals with Parkinson ’s disease ( PD ) ; however , its effect on clinical outcomes remains largely unknown . Objective . To evaluate the short-term effects of the HiBalance program , a highly challenging balance-training regimen that incorporates both dual-tasking and PD-specific balance components , compared with usual care in elderly with mild to moderate PD . Methods . Participants with PD ( n = 100 ) were r and omized , either to the 10-week  HiBalance program  ( n = 51 ) or to the  control group ( n = 49 ) . Participants were evaluated before and after the intervention . The main outcomes were balance performance ( Mini-BESTest ) , gait velocity ( during normal and dual-task gait ) , and concerns about falling ( Falls Efficacy Scale – International ) . Performance of a cognitive task while walking , physical activity level ( average steps per day ) , and activities of daily living were secondary outcomes . Results . A total of 91 participants completed the study . After the intervention , the between group comparison showed significantly improved balance and gait performance in the training group . Moreover , although no significant between group difference was observed regarding gait performance during dual-tasking ; the participants in the training group improved their performance of the cognitive task while walking , as compared with the control group . Regarding physical activity levels and activities of daily living , in comparison to the control group , favorable results were found for the training group . No group differences were found for concerns about falling . Conclusions . The HiBalance program significantly benefited balance and gait abilities when compared with usual care and showed promising transfer effects to everyday living . Long-term follow-up assessment s will further explore these effects Objective : To investigate the effect of home exercises on the motor performance of patients with Parkinson 's disease . Design : A prospect i ve blinded study with allocation of patients into their groups by alternate weeks . Setting : A University Hospital neurology and physiotherapy department . Subjects : Recruited from a movement disorders outpatient clinic of Cerrahpasa School of Medicine diagnosed with Parkinson 's disease , classified as Hoehn and Yahr Grade s I , II and III . Interventions : Patients who fulfilled the inclusion criteria were recruited to the study . Each patient was evaluated at the end of first and second month after the baseline evaluation . Patients were divided into two groups . Those in the first and third week were put in the exercise group and second and fourth week in the control group . Patients in the exercise group ( n=15 ) were given a schedule of exercises to undertake at home ; the others ( n=15 ) did not receive this instruction . Measures : Ten- and 20-m walking test , first pace length , pace number in 10 m , walking around a chair , Nine Hole Peg Board ( NHPB ) test . Results : Following the home exercise programme , patients in the exercise group showed improvement in walking 10 and 20 m , time elapsed to complete walking around a chair and length of the first pace length , and in the motor performance of both h and s ( p < 0.001 ) . Conclusions : A home-based rehabilitation programme for patients with Parkinson 's disease helped to improve motor performance compared to patients who did not take advantage of a regular , professionally design ed exercise programme BACKGROUND AND PURPOSE The Timed " Up & Go " Test ( TUG ) is used to measure the ability of patients to perform sequential locomotor tasks that incorporate walking and turning . This study investigated the retest reliability , interrater reliability , and sensitivity of scores obtained with the TUG in detecting changes in mobility in subjects with idiopathic Parkinson disease ( PD ) . SUBJECTS The performance of 12 people with PD was compared with that of 12 age-matched comparison subjects without PD . METHODS The subjects with PD completed 5 trials of the TUG after withdrawal of levodopa for 12 hours ( " off " phase of the medication cycle ) as well as an additional 5 trials 1 hour after levodopa was administered ( " on " phase of the medication cycle ) . They were scored on the Modified Webster Scale at both sessions . The comparison subjects also performed 5 TUG trials . All trials were videotaped and timed by 2 experienced raters . The videotape was later rated by 3 experienced clinicians and 3 inexperienced clinicians . RESULTS For the subjects with PD , within-session performance was highly consistent , with correlations ( r ) ranging from.80 to.98 for the " off " phase and from.73 to.99 for the " on " phase . The performance of the comparison subjects across the 5 trials was also highly consistent ( r=.90-.97 ) . Comparisons showed differences between trials 1 and 2 on the TUG for both groups . Removal of data for trial 1 ( the practice trial ) further enhanced retest reliability . There was close agreement in TUG scores among raters despite different levels of experience ( intraclass correlation coefficient [3,1]=.87-.99 ) . Mean TUG scores were different between the " on " and " off " phases of the levodopa cycle and between subjects with PD and comparison subjects during the " on " phase . CONCLUSION AND DISCUSSION Retest reliability and interrater reliability of the TUG measurements were high , and the measurements reflected changes in performance according to levodopa use . The TUG can also be used to detect differences in performance between people with PD and elderly people without PD Background Recently , a new tool for assessing dynamic balance impairments has been presented : the 14-item Mini-BESTest . Objective The aim of this study was to compare the psychometric performance of the Mini-BESTest and the Berg Balance Scale ( BBS ) . Design A prospect i ve , single-group , observational design was used in the study . Methods Ninety-three participants ( mean age=66.2 years , SD=13.2 ; 53 women , 40 men ) with balance deficits were recruited . Interrater ( 3 raters ) and test-retest ( 1–3 days ) reliability were calculated using intraclass correlation coefficients ( ICCs ) . Responsiveness and minimal important change were assessed ( after 10 sessions of physical therapy ) using both distribution-based and anchor-based methods ( external criterion : the 15-point Global Rating of Change [ GRC ] scale ) . Results At baseline , neither floor effects nor ceiling effects were found in either the Mini-BESTest or the BBS . After treatment , the maximum score was found in 12 participants ( 12.9 % ) with BBS and in 2 participants ( 2.1 % ) with Mini-BESTest . Test-retest reliability for total scores was significantly higher for the Mini-BESTest ( ICC=.96 ) than for the BBS ( ICC=.92 ) , whereas interrater reliability was similar ( ICC=.98 versus .97 , respectively ) . The st and ard error of measurement ( SEM ) was 1.26 and the minimum detectable change at the 95 % confidence level ( MDC95 ) was 3.5 points for Mini-BESTest , whereas the SEM was 2.18 and the MDC95 was 6.2 points for the BBS . In receiver operating characteristic curves , the area under the curve was 0.92 for the Mini-BESTest and 0.91 for the BBS . The best minimal important change ( MIC ) was 4 points for the Mini-BESTest and 7 points for the BBS . After treatment , 38 participants evaluated with the Mini-BESTest and only 23 participants evaluated with the BBS ( out of the 40 participants who had a GRC score of ≥3.5 ) showed a score change equal to or greater than the MIC values . Limitations The consecutive sampling method drawn from a single rehabilitation facility and the intrinsic weakness of the GRC for calculating MIC values were limitations of the study . Conclusions The 2 scales behave similarly , but the Mini-BESTest appears to have a lower ceiling effect , slightly higher reliability levels , and greater accuracy in classifying individual patients who show significant improvement in balance function OBJECTIVE To assess the criterion-related validity of the  Berg Balance Scale ( BBS ) in subjects with Parkinson 's disease ( PD ) . DESIGN Prospect i ve , correlational analysis between the BBS and accepted measures of PD motor and functional impairment . SETTING The federally funded PD research center , an interdisciplinary center of excellence for people with PD within a Veterans Affairs medical center . PARTICIPANTS Thirty-eight men ( average + /- st and ard deviation , 71.1+/-10.5 y ) with confirmed PD . Their initial diagnosis had been made on average 5.8+/-3.6 years earlier . All could st and or walk unassisted and had mild to moderate disability . Patients who could not ambulate without assistive devices were excluded . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Correlational analyses between the  BBS  and the Unified Parkinson 's Disease Rating Scale ( UPDRS ) motor scale , Modified Hoehn and Yahr Staging ( Hoehn and Yahr ) Scale , and the Modified Schwab and Engl and Capacity for Daily Living Scale ( S&E ADL Scale ) . RESULTS BBS score showed significant correlations with indicators of motor functioning , stage of disease , and daily living capacity . BBS score was inversely associated with the UPDRS motor score ( -.58 , P < .005 ) , Hoehn and Yahr Scale staging ( -.45 , P < .005 ) , and S&E ADL Scale rating ( .55 , P < .005 ) . In all 3 correlations , lower scores on the BBS ( indicating greater balance deficits ) correlated with higher UPDRS scores ( indicating greater motoric or functional impairment ) . CONCLUSIONS Results support the criterion-related validity of the BBS . Its utility in other balance conditions of older adults has been established . Rehabilitation interventions have been shown to improve the balance deficits associated with PD . Early referral and periodic re assessment is vital to achieving and maintaining improvements . Our research results agree with other published research in suggesting that the BBS may be used as a screening tool and ongoing assessment tool for patients with PD BACKGROUND AND PURPOSE Assessment of the quality of r and omized controlled trials ( RCTs ) is common practice in systematic review s. However , the reliability of data obtained with most quality assessment scales has not been established . This report describes 2 studies design ed to investigate the reliability of data obtained with the Physiotherapy Evidence Data base ( PEDro ) scale developed to rate the quality of RCTs evaluating physical therapist interventions . METHOD In the first study , 11 raters independently rated 25 RCTs r and omly selected from the PEDro data base . In the second study , 2 raters rated 120 RCTs r and omly selected from the PEDro data base , and disagreements were resolved by a third rater ; this generated a set of individual rater and consensus ratings . The process was repeated by independent raters to create a second set of individual and consensus ratings . Reliability of ratings of PEDro scale items was calculated using multirater kappas , and reliability of the total ( summed ) score was calculated using intraclass correlation coefficients ( ICC [ 1,1 ] ) . RESULTS The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters . The ICC for the total score was.56 ( 95 % confidence interval=.47-.65 ) for ratings by individuals , and the ICC for consensus ratings was.68 ( 95 % confidence interval=.57-.76 ) . DISCUSSION AND CONCLUSION The reliability of ratings of PEDro scale items varied from " fair " to " substantial , " and the reliability of the total PEDro score was " fair " to " good . Objective : To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson ’s disease ( PD ) . Method : Patients with a confirmed diagnosis of idiopathic PD , independently mobile , living at home in the community , experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this r and omised controlled trial . Usual care was compared with a personalised 6 week , home based exercise and strategy programme . The primary outcomes were rates of falling at 8 weeks and 6 months . Whether participants had repeat fallen , nearly fallen or experienced injurious falls were also examined . Functional Reach , the Berg Balance Test , PD Self- assessment Scale and the Euro Quol were rated by a blinded assessor . Results : Participants were r and omised to the exercise ( n = 70 ) and control ( n = 72 ) groups . There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months . Lower rates of repeat near falling were evident for the exercise group at 8 weeks ( p = 0.004 ) and 6 months ( p = 0.007 ) . There was a positive effect of exercises at 6 months on Functional Reach ( p = 0.009 ) and quality of life ( p = 0.033 ) . No significant differences were found on other secondary outcomes measures . Conclusion : There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life Background . Falls are common and disabling in people with Parkinson ’s disease ( PD ) . There is a need to quantify the effects of movement rehabilitation on falls in PD . Objective . To evaluate 2 physical therapy interventions in reducing falls in PD . Methods . We r and omized 210 people with PD to 3 groups :  progressive resistance strength training coupled with falls prevention education , movement strategy training combined with falls prevention education , and life-skills information ( control ) . All received 8 weeks of out-patient therapy once per week and a structured home program . The primary end point was the falls rate , recorded prospect ively over a 12 month period , starting from the completion of the intervention . Secondary outcomes were walking speed , disability , and quality of life . Results . A total of 1547 falls were reported for the trial . The falls rate was higher in the control group compared with the groups that received strength training or strategy training . There were 193 falls for the progressive resistance strength training group , 441 for the movement strategy group and 913 for the control group . The strength training group had 84.9 % fewer falls than controls ( incidence rate ratio [ IRR ] = 0.151 , 95 % CI 0.071 - 0.322 , P < .001 ) . The movement strategy training group had 61.5 % fewer falls than controls ( IRR = 0.385 , 95 % CI 0.184 - 0.808 , P = .012 ) . Disability scores improved in the intervention groups following therapy while deteriorating in the control group . Conclusions . Rehabilitation combining falls prevention education with strength training or movement strategy training reduces the rate of falls in people with mild to moderately severe PD and is feasible Objectives : Gait and mobility problems are difficult to treat in people with Parkinson ’s disease . The Rehabilitation in Parkinson ’s Disease : Strategies for Cueing ( RESCUE ) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity . Methods : A single-blind r and omised crossover trial was set up , including 153 patients with Parkinson ’s disease aged between 41 and 80 years and in Hoehn and Yahr stage II – IV . Subjects allocated to early intervention ( n = 76 ) received a 3-week home cueing programme using a prototype cueing device , followed by 3 weeks without training . Patients allocated to late intervention ( n = 77 ) underwent the same intervention and control period in reverse order . After the initial 6 weeks , both groups had a 6-week follow-up without training .  Posture and gait scores ( PG scores ) measured at 3 , 6 and 12 weeks by blinded testers were the primary outcome measure . Secondary outcomes included specific measures on gait , freezing and balance , functional activities , quality of life and carer strain . Results : Small but significant improvements were found after intervention of 4.2 % on the PG scores ( p = 0.005 ) . Severity of freezing was reduced by 5.5 % in freezers only ( p = 0.007 ) . Gait speed ( p = 0.005 ) , step length ( p<0.001 ) and timed balance tests ( p = 0.003 ) improved in the full cohort . Other than a greater confidence to carry out functional activities ( Falls Efficacy Scale , p = 0.04 ) , no carry-over effects were observed in functional and quality of life domains . Effects of intervention had reduced considerably at 6-week follow-up . Conclusions : Cueing training in the home has specific effects on gait , freezing and balance . The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment . Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson ’s disease Background and Purpose : Comparative studies of exercise interventions for people with Parkinson disease ( PD ) rarely considered how one should deliver the intervention . The objective of this study was to compare the success of exercise when administered by ( 1 ) home exercise program , ( 2 ) individualized physical therapy , or ( 3 ) a group class . We examined if common comorbidities associated with PD impacted success of each intervention . Methods : Fifty-eight people ( age = 63.9 ± 8 years ) with PD participated . People were r and omized into ( 1 ) home exercise program , ( 2 ) individual physical therapy , or ( 3 ) group class intervention . All arms were st and ardized and based on the Agility Boot Camp exercise program for PD , 3 times per week for 4 weeks . The primary outcome measure was the 7-item Physical Performance Test . Other measures of balance , gait , mobility , quality of life , balance confidence , depressions , apathy , self-efficacy and UPDRS-Motor , and activity of daily living scores were included . Results : Only the individual group significantly improved in the Physical Performance Test . The individual exercise showed the most improvements in functional and balance measures , whereas the group class showed the most improvements in gait . The home exercise program improved the least across all outcomes . Several factors effected success , particularly for the home group . Discussion and Conclusions : An unsupervised , home exercise program is the least effective way to deliver exercise to people with PD , and individual and group exercises have differing benefits . Furthermore , people with PD who also have other comorbidities did better in a program directly supervised by a physical therapist . Video Abstract available for additional insights from the authors ( see Video , Supplemental Digital Content 1 , http://links.lww.com/JNPT/A112 ) Objectives To compare the effectiveness of an exercise programme with usual care in people with Parkinson 's disease ( PD ) who have a history of falls . Design Pragmatic r and omised controlled trial . Setting Recruitment was from three primary and four secondary care organisations , and PD support groups in South West Engl and . The intervention was delivered in community setting s. Participants People with PD , with a history of two or more falls in the previous year , who were able to mobilise independently . Intervention 10 week , physiotherapy led , group delivered strength and balance training programme with supplementary home exercises ( intervention ) or usual care ( control ) . Main outcome measure Number of falls during the ( a ) 10 week intervention period and ( b ) the 10 week follow-up period . Results 130 people were recruited and r and omised ( 64 to the intervention ; 66 to usual care ) . Seven participants ( 5.4 % ) did not complete the study . The incidence rate ratio for falls was 0.68 ( 95 % CI 0.43 to 1.07 , p=0.10 ) during the intervention period and 0.74 ( 95 % CI 0.41 to 1.33 , p=0.31 ) during the follow-up period . Statistically significant between group differences were observed in Berg balance , Falls Efficacy Scale-International scores and recreational physical activity levels . Conclusions The study did not demonstrate a statistically significant between group difference in falls although the difference could be considered clinical ly significant . However , a type 2 error can not be ruled out . The findings from this trial add to the evidence base for physiotherapy and exercise in the management of people with PD . Trial registration IS RCT N50793425 AIM This study aim ed to evaluate the feasibility and cultural considerations of a minimally supervised , home-based exercise program in Jordan . METHODS Quantitative and qualitative approaches were used . Thirty participants were r and omly allocated to either an 8-week intervention group ( n = 16 ) , or a st and ard care group ( n = 14 ) . The intervention incorporated the home use of an exercise DVD , walking program and initial instructional sessions and weekly phone calls provided by a physiotherapist . Interviews were used to explore feasibility . Unified Parkinson 's disease rating scale ( UPDRS-III ) ; balance and walking speed were assessed . RESULTS The retention rate was 86.7 % and mean adherence rate was 77 % . Personal and sociocultural barriers of adherence to the exercise program were identified . UPDRS-III at follow-up was lower in the intervention group . CONCLUSION A home exercise program was feasible . Sociocultural barriers specific to Arabic culture may affect the uptake of such an intervention in Parkinson 's disease in these countries Objectives : To determine long-term effects of a highly challenging training program in people with Parkinson ’s disease , as well as describe how initially observed improvements of the program deteriorated over time . Design : Long-term follow-up of previously reported outcomes at 10 weeks of a r and omized controlled trial . Setting : University hospital setting . Participants : One-hundred elderly with mild-to-moderate ( Hoehn and Yahr 2–3 ) Parkinson ’s disease . Interventions : Participants in the training group ( n = 51 ) received 10 weeks ( three times/week ) of balance and gait exercises , incorporating dual-tasks , while the control group ( n = 49 ) received care as usual . Main Outcome Measures : Balance control ( Mini-Balance Evaluation System Test ( Mini-BESTest ) ) and gait velocity . Mixed- design analyses of variance were used to determine potential training effects at 6- and 12-month follow-up , and piecewise regression models predicted the rate of deterioration . Results : Seventy-six participants were included at final follow-up . No significant ( P > .05 ) between-group differences remained at either 6 or 12 months following the intervention . The mean Mini-BESTest scores of the training and control group were 19.9 ( SD 4.4 ) and 18.6 ( SD 4.3 ) , respectively , at the 12-month follow-up . Gait speed was 1.2 ( SD 0.2 ) m/s in both groups at 12 months . The training group showed a larger deterioration rate per month in balance performance ( 0.21 point ) and gait velocity ( 0.65 cm/s ) than controls ( P < .05 ) . Conclusion : These results suggest that training effects diminish within 6 months after balance training , implying that the program may need to be repeated regularly Objective To examine mortality and associated risk factors , including possible effects of mild cognitive impairment , imaging , and CSF abnormalities , in a community-based population with incident parkinsonism and Parkinson disease . Methods One hundred eighty-two patients with new-onset , idiopathic parkinsonism were diagnosed from January 2004 through April 2009 , in a catchment area of 142,000 inhabitants in Sweden . Patients were comprehensively investigated according to a multimodal research protocol and followed prospect ively for up to 13.5 years . A total of 109 patients died . Mortality rates in the general Swedish population were used to calculate st and ardized mortality ratio and expected survival , and Cox proportional hazard models were used to investigate independent predictors of mortality . Results The st and ardized mortality ratio for all patients was 1.84 ( 95 % confidence interval 1.50–2.22 , p < 0.001 ) . Patients with atypical parkinsonism ( multiple system atrophy or progressive supranuclear palsy ) had the highest mortality . In early Parkinson disease , a mild cognitive impairment diagnosis , freezing of gait , hyposmia , reduced dopamine transporter activity in the cau date , and elevated leukocytes in the CSF were significantly associated with shorter survival . Conclusion Although patients presenting with idiopathic parkinsonism have reduced survival , the survival is highly dependent on the type and characteristics of the parkinsonian disorder . Patients with Parkinson disease presenting with normal cognitive function seem to have a largely normal life expectancy . The finding of a subtle CSF leukocytosis in patients with Parkinson disease with short survival may have clinical implication Objective To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson ’s ( PwP ) . Methods People at risk of falls with confirmed Parkinson ’s were recruited to this multicentre , pragmatic , investigator blind , individually r and omised controlled trial with prespecified subgroup analyses . 474 PwP ( Hoehn and Yahr 1–4 ) were r and omised : 238 allocated to a physiotherapy programme and 236 to control .  All participants had routine care ; the control group received a DVD about Parkinson ’s and single advice session at trial completion . The intervention group ( PDSAFE ) had an individually tailored , progressive home-based fall avoidance strategy training programme with balance and strengthening exercises . The primary outcome was risk of repeat falling , collected by self-report monthly diaries , 0–6 months after r and omisation . Secondary outcomes included Mini-BESTest for balance , chair st and test , falls efficacy , freezing of gait , health-related quality of life ( EuroQol EQ-5D ) , Geriatric Depression Scale , Physical Activity Scale for the Elderly and Parkinson ’s Disease Question naire , fractures and rate of near falling . Results Average age is 72 years and 266 ( 56 % ) were men . By 6 months , 116 ( 55 % ) of the control group and 125 ( 61.5 % ) of the intervention group reported repeat falls ( controlled OR 1.21 , 95 % CI 0.74 to 1.98 , p=0.447 ) . Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups . Balance , falls efficacy and chair st and time improved with near falls reduced in the intervention arm . Conclusion PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease . Trial registration number IS RCT N48152791
target: Home-based prescribed exercise improves balance-related activities and gait speed in people with Parkinson 's disease , and these improvements are similar to improvements with equivalent centre-based exercise .
background: QUESTIONS In people with Parkinson 's disease , does home-based prescribed exercise improve balance-related activities and quality of life compared with no intervention ?
  Are the effects of home-based exercise similar to those of equivalent centre-based exercise ?