EU Physiotherapy Guideline For Parkinson's Disease

European
Physiotherapy
Guideline for
Parkinson’s Disease
Developed with twenty European professional associations
Development and scientific justification
Samyra Keus, Marten Munneke, Mariella Graziano, Jaana Paltamaa, Elisa Pelosin, Josefa Domingos, Susanne
Brühlmann, Bhanu Ramaswamy, Jan Prins, Chris Struiksma, Lynn Rochester, Alice Nieuwboer, Bastiaan Bloem;
On behalf of the Guideline Development Group
European Physiotherapy Guideline for Parkinson’s disease © ParkinsonNet | KNGF 2014
The development of this guideline was initiated and mainly

financed by ParkinsonNet and the Royal Dutch Society for
Physical Therapy (KNGF), the Netherlands
This Guideline is endorsed by the Association for
Physiotherapists in Parkinson’s Disease Europe (APPDE),
the European Parkinson’s Disease Association (EPDA) and
Contents
the European Region of the World Confederation for Physical European Physiotherapy Guideline for Parkinson's Disease............................................................................. 4
Therapy (ER-WCPT). 1.2 The Guideline Development Group....................................................................................................... 4
1.3 Timeline............................................................................................................................................... 4
1.4 Identifying barriers in current care......................................................................................................... 4
1.5 Literature search.................................................................................................................................. 6
1.6 Using GRADE to develop recommendations........................................................................................ 8
1.7 Selecting physiotherapy measurement tools........................................................................................ 9
1.8 Update of this Guideline..................................................................................................................... 10
Appendix 14 Graded classes of outcomes.................................................................................................... 11
Appendix 15 Overview of excluded CCTs: reasons for exclusion.................................................................... 14

Appendix 16 Measurement tools considered for recommendation................................................................. 15
Appendix 17 Evidence-grading tables to the intervention recommendations.................................................. 31
App. 17.1 Conventional physiotherapy versus no intervention or placebo................................................ 32
App. 17.2 Treadmill versus no treadmill training........................................................................................ 35

App. 17.3 Whole body vibration (WBV) versus no WBV............................................................................ 36
App. 17.4 Massage of trigger points: neuromuscular therapy versus no neuromuscular therapy.............. 37
App. 17.5 Cueing versus no cueing......................................................................................................... 38
App. 17.6 Strategies for complex motor sequences supported by cueing................................................ 40
App. 17.7 Dance versus no dance (tango)............................................................................................... 41
App. 17.8 Tai Chi versus no Tai Chi.......................................................................................................... 42
Reference List............................................................................................................................................... 43
Available for downloading at www.parkinsonnet.info/euguideline are Reference to this publication

Keus SHJ, Munneke M, Graziano M, et al. European Physiotherapy
- Guideline
Guideline for Parkinson’s disease. 2014; KNGF/ParkinsonNet, the
- Guideline information for people with Parkinson's
Netherlands
- Guideline information for clinicians
- Development and scientific justification (this document) Copyright © 2014 KNGF/ParkinsonNet

All rights reserved. No part of this publication may be reproduced,
transmitted or stored in a retrieval system of any nature, in any form or
1st edition, December 2014
by any means, without prior permission in writing of the copyright owner.
A link to a pdf of this publication is available on www.parkinsonnet.info/
euguideline. This link may be used without prior permission.
Design by Puntkomma
2 3
European Physiotherapy Guideline for Parkinson's Disease care organisation. Aiming to provide recommendations to optimise care, as a first step, the GDG gained insight into barriers
Parkinson’s disease, or Parkinson’s, is a complex disorder. It is characterised by a wide array of motor and non-motor physiotherapists currently experience when wishing to provide intervention to pwp. These were identified by means of a
problems for which medical intervention alone is insufficient. Many allied health professionals can be involved in the web-based survey sent to 9,646 physiotherapists of 17 European countries11. Of the responding 3,405 physiotherapists,
management of Parkinson’s disease, of which physiotherapy is the most applied and supported by scientific evidence. In 84% had treated at least one pwp the past year, and identified many barriers to delivery of optimal care (Table 1.4a).
2004, the Royal Dutch society for Physical Therapy (KNGF) published the first evidence-informed guideline with practice Through focus groups with 50 expert users, and with Dutch ParkinsonNet physiotherapists, points for improvement of the
recommendations for physiotherapy in Parkinson’s. An external audit in 2008 showed that this Guideline is one of the few 2004 KNGF Guideline were identified (Table 1.4b). In addition, barriers in current care reported by pwp and therapists were
Parkinson’s disease guidelines that are of good quality. Following a request from the Association of Physiotherapists in indentified in the international literature using the search terms ‘"Patient's perspective" OR "Patient Satisfaction"[Mesh])
Parkinson’s disease Europe (APPDE), the KNGF agreed upon a proposal of ParkinsonNet to update and adapt the Guideline AND "Parkinson Disease"[Mesh]’ (Table 1.4c)16-22. The GDG used these barriers and suggestions for improvement in the
into a European guideline. The APPDE, the European Region of the World Confederation for Physical Therapy (ER-WCPT) development of this Guideline by transforming them into key questions. For example, What are the consequences of
and the European Parkinson’s Disease Association (EPDA), an umbrella organisation representing 45 national member cognitive impairments for physiotherapy treatment? and What treatment strategies improve the performance of walking?
organisations (www.epda.eu.com) endorsed the development. Representatives of as many as 20 member organisations
of the ER-WCPT, as well as representatives of Parkinson associations participated in the development process.
The GDG developed this Guideline according to international standards for guideline development, addressing all items Table 1.4a Physiotherapist’ perceived barriers in delivering optimal care to pwp
of the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE, www.agreetrust.org) and using ‘Grading Low The median annual treatment volume* reported was as low as 4, ranging from 2 to 5 in different
treatment countries. The reported optimum annual treatment volume to gain and maintain Parkinson
of Recommendations Assessment, Development and Evaluation’ (GRADE) to develop the recommendations.
volume expertise was 10
1.2 The Guideline Development Group Limited The majority reported limited Parkinson’s specific knowledge and skills: only 16% reported
knowledge & (very) high self-perceived Parkinson-expertise, increasing to 26% in physiotherapists with a
In 2011, all 20 physiotherapy participating associations nominated a representative for the Writing Group, the Reading
skills treatment volume ≥5
Group or the Review Panel. Together these groups make up the Guideline Development Group (GDG). None of the GDG
Referral To 33%, referral at too late a stage was a major barrier. Even though physiotherapy is
members had an intellectual conflict of interest. Selection criteria for Writing Group members were geographic dispersion at too late a important from disease onset, most of the pwp treated were in the complicated phase (HY 3
stage and 4)
throughout Europe and a good balance between clinical and research Parkinson-specific expertise. Through the EPDA
and the Dutch Parkinson association, pwp fully participated in both the Writing and Reading Group. Time constraints One in three physiotherapists reported limited time with the pwp as a major barrier.
Parkinson’s disease is a complex condition involving slowness of movement, speech and
An international Steering Group evaluated the development process. Members of this group had extended expertise in thinking. As a result, physiotherapy assessment and treatment for pwp requires more time
than other patient groups
physiotherapy, neurology, Parkinson’s disease, the pwp' perspective and guideline development in general.
Collaboration 25% would like more communication with their peers on pwp and related issues
1.3 Timeline Measurement 40% of experts did not use measurement tools. The main reasons were lack of time (32%),
tools insufficient knowledge and skills (29%), difficulty interpreting results (25%) and unavailability
In 2011, after the initiation of the European survey, the 10 Writing Group members started their activities11. They prepared of tools (23%). Also tools not recommended in the 2004 Guideline are used, such as Berg
the first drafts of the key questions to be addressed, the overall contents of the Guideline, the literature review and the Balance and Tinetti Balance & Gait
recommendations. For this, they met three times: June 2011, February and November 2012. Furthermore, the GDG Intervention Less than 60% of therapists applied cognitive movement strategies and physical capacity
training, recommended by the KNGF Guideline. For most interventions, only 50% of
communicated electronically. Members of the Reading Group provided feedback at eight points during the development physiotherapists felt above average competence applying them.
process, between February 2012 and May 2014. Members of the Review Panel provided feedback on two penultimate *unique number of pwp assessed and, if indicated, treated annually
versions: October 2013 and April 2014. These versions were also published online for public feedback. Finally, at the time
of publication of this Guideline, Parkinson-expert neurologists, members of the European Section of the Parkinson and
Movement Disorder Society are reviewing the referral criteria as described in the Section for clinicians. Their Viewpoint Table 1.4b Parkinson expert physiotherapists information needs
will be published in the MDS online journal Clinical Practice. • How to recognise atypical parkinsonisms from Parkinson’s disease?
• How do impairments in cognition and co-morbidities influence physiotherapy treatment?
• What are referral criteria for other health professionals?
1.4 Identifying barriers in current care • How to optimise communication with other health professionals, including referring physicians?
• How to use and interpreted measurement tools?
The 2004 KNGF-Guideline Parkinson’s disease, unique in its field, was the starting point for the development of this • Why are certain measurement tools not recommended?
European Guideline12;13. In addition, the GDG used the 2010 Dutch Multidisciplinary Guideline for Parkinson’s disease14. • How to discuss expectations towards the intervention with the pwp?
• How to support self-management, especially after completion of a treatment period?
The Dutch Multidisciplinary Guideline is an update of the 2006 National Institute for Health and Clinical Excellence (NICE) • What are the general contents of a group treatment protocol?
Guideline published in the United Kingdom (UK)15, extended with recommendations for interdisciplinary collaboration and
4 5
Table 1.4c Pwp needs towards optimal care Table 1.5b Strategy systematic literature search
Contents of care Organisation of care Step Aim Search Hits

• Information about the expected treatment effect • Care by specialised healthcare providers
• Taking into account fluctuations in daily functioning • Active involvement in clinical decision making 1 Parkinson’s "Parkinson Disease"[Mesh] AND "Parkinson Disease, Secondary"[Mesh] 80,891
• Information on mobility and exercise • Possibility to choose own physiotherapist OR Parkinson OR "Parkinson’s disease" OR parkinsonism
• Discussion of the role of the carer • Treatment at home
• Self-management support • Parkinson’s specific knowledge in home care 2 Physiotherapy "Physical Therapy (Specialty) "[MESH] OR "Physical Therapy 631,534
• Emotional support, such as interest, motivation, professionals Modalities"[MESH] OR Rehabilitation [MESH] OR Exercise[MESH] OR
taken seriously • Multidisciplinary collaboration: avoid conflicting "Exercise Therapy"[MESH] OR "Resistance Training"[MESH] OR "Muscle
information and advise; information exchange Stretching Exercises"[MESH] OR "Breathing Exercises"[MESH] OR
Physiotherapy OR "physical therapy" OR exercise OR rehabilitation
3 Combine 1 & 2 #1 AND #2 4,683
1.5 Literature search
4 RCTs/CCTs (randomised controlled trial [pt] OR controlled clinical trial [pt] OR 767,963
The GDG determined which of the key questions could feasibly be addressed by undertaking a systematic literature search. randomised [tiab] OR placebo [tiab] OR clinical trials as topic [mesh:
The aim was to identify al all controlled clinical trials (CCTs) in the field: trials in which two groups of pwp participated, of noexp] OR randomly [tiab] OR trial [ti]) NOT (animals [mh] NOT humans
[mh])
which at least one received a physiotherapy intervention. The GDG used literature search filters of the Cochrane Collaboration23,
5 Systematic ((“meta-analysis” [pt] OR “meta-anal*” [tw] OR “metaanal*” [tw] OR 48,334
with the exception that next to RCTs also not randomised controlled clinical trials were identified (Table 1.5b). In addition, reviews (“quantitativ* review*” [tw] OR “quantitative* overview*” [tw] ) OR
the GDG searched PEDRO using the wildcards ‘Parkinson’ and ‘Parkinson’s’, and Writing and Reading Group members (“systematic* review*” [tw] OR “systematic* overview*” [tw]) OR
(“methodologic* review*” [tw] OR “methodologic* overview*” [tw]) OR
contributed trials not yet identified. The GDG addressed all others questions by expert opinion and a non-systematic (“review” [pt] AND “medline” [tw])) AND ("2008/01/01"[PDAT] :
"2012/31/12"[PDAT])
literature search in PubMed up and to December 2012.
6 Guidelines ((“guideline” [pt] OR “practice guideline” [pt] OR “health planning 18,953
guidelines” [mh] OR “consensus development conference” [pt] OR
Of the 122 CCTs identified, the GDG excluded 52 for various reasons (Appendix 15)24-75. The GDG categorised the 70 “consensus development conference, nih” [pt] OR “consensus
development conferences” [mh] OR “consensus development
remaining CCTs according to the evaluated physiotherapy interventions (Table 1.5c)76-145.
conferences, nih” [mh] OR “guidelines” [mh] OR “practice guidelines”
[mh] OR (consensus [ti] AND statement [ti]))) AND ("2003/01/01"[PDAT]
: "2012/31/12"[PDAT])
Table 1.5a Key questions for which a systematic literature was carried out 7 Combine 3 & 4 #3 AND #4 618
Contents of care 8 Combine 3 & 5 #3 AND #5 47

• What treatment strategies improve performance of transfers? 9 Combine 3 & 6 #3 AND #6 9
• What treatment strategies improve performance of manual activities?
• What treatment strategies improve performance of balance? 10 ("Patient's perspective" OR "Patient Satisfaction"[Mesh]) AND #3 133
• What treatment strategies improve performance of gait?
• What treatment strategies improve performance of physical capacity?
• What treatment strategies improve respiratory functions?
• What treatment strategies reduce pain?
Table 1.5c Categories of physiotherapy interventions for pwp
• Conventional physiotherapy
• Treadmill training
• Cueing
• Strategies for complex motor sequences
• Massage
• Martial arts
• Dance
6 7
1.6 Using GRADE to develop recommendations Table 1.6b Statistics and formulae used for individual studies147
Most guideline panels have used letters and numbers to summarise their recommendations, but they have used them with Statistic Formula
little uniformity to establish a best method . The GDG has appraised evidence using GRADE, Grading of Recommendations
146
Pooled standard deviation √(n1-1)sd12+(n2-1)sd22/(N-2)
Assessment Development and Evaluation (www.GRADEworkinggroup.org). GRADE is endorsed by many major organisations across groups (sd) When the sd of the response was not provided, pre-measurement sd was used
such as the Cochrane Collaboration, the World Health Organisation, the UK National Institute for Health and Clinical
Mean Difference (MD) m1 - m2 (response experimental minus mean response control)
Excellence and the British Medical Journal. With GRADE, the GDG graded the ‘body of evidence’ for each key question, With standard error (SE) = √((sd12/n1)+( sd22/n1))
instead of for separate publications as was common in 2004 (Fig. 1.6).
Standardised MD (SMD) (m1 - m2)/s * (1-(3/(4N-9)))
With SE = √((N/n1*n2)+(SMD2/(2(N-3.94))))
Fig. 1.6 From key questions to recommendations
Confidence interval MD or SMD ± 1.96*SE

Rate importance of Select outcomes
Key question Identify outcomes
outcomes rated > 7/10
For estimation of the intervention effect, the Mean Difference (MD) or Standardised Mean Difference (SMD) was used (Table
1.6b)23. The MD and its 95% confidence interval (CI) are used when studies use an identical outcome measurement. The
MD expresses the size of the intervention effect on the scale used. The CI expresses the range within which we can be
95% certain that the true effect lies. The SMD and its CI are used when studies assess the same outcome, but measure
For or against and Weight benefits High, Moderate, GRADE the body of
strong or weak & burden Low, or Very low evidence it in a variety of ways. The SMD expresses the size of the intervention effect relative to the variability. The SMD is adjusted
for sample size using Hedge’s g effect size matrix.
The GDG formulated key questions based on the barriers identified; classified the outcomes used in the identified CCTs Initially, aiming to keep the development time and thus costs of this Guideline reasonable, the GDG intended to use MD’s
into capacity or performance measures on the different International Classification of Functioning (ICF) domains and scored and SMD’s from published meta-analysis. Over the past years, several systematic reviews including meta-analyses reviewing
the importance of the classes of outcomes. Only outcomes with a mean score of 6.5 or above on a scale of one to 10, the efficacy of physiotherapy for pwp have been published. However, it appeared that for one key question, different meta-
that is critical outcomes, were used for the evidence grading (Appendix 14). Next, the GDG extracted all trial details analysis included different CCTs. Moreover, some CCTs selected by the GDG were not included the meta-analysis. Therefore,
necessary for the grading process and graded the quality of the evidence for each question and outcome: high, moderate, the GDG performed a meta-analysis, using RevMan software (Cochrane Collaboration; http://tech.cochrane.org/Revman)
low or very low. All CCTs started at the high level. Possible reasons for downgrading were risk of bias, inconsistency, to calculate the MD or SMD.
indirectness or imprecision of the results and publication bias (Table 1.6a). For each reason the GDG lowered the quality
level by one level in case of a serious limitations, or by two levels in case of a very serious limitation. Limitations not Finally, the GDG graded the recommendations as ‘strong’ or ‘weak’. This strength reflects the generalisability of the effects
expected to influence the outcome did not result in downgrading. amongst all pwp; the extent to which the benefits of the intervention outweigh undesirable effects (such as falls, burden
of treatment and costs); the availability; and the values and preferences of pwp and therapists, if known148.
Table 1.6a Possible reasons for downgrading of the quality of evidence 1.7 Selecting physiotherapy measurement tools
Reason Example Use of measurement tools supports structured, objective and transparent assessment, evaluation and communication.
Risk of bias* Design limitations, such as no (report of) randomisation procedure*, blinding*, allocation However, this only is the case when appropriate tools are selected and the results well interpreted. The GDG has selected
concealment* or intention to treat analyses*, or high numbers of drop outs* outcome measures for use in routine practice in individual pwp.
Inconsistency Differences in direction and size of the effect To determine the final set of tools, first the GDG checked the overview of tools recommended in the current Guideline149,
Indirectness Differences in intervention, people (in our case pwp and therapists) or outcome measures identified through the European survey11 or focus groups with Parkinson expert physiotherapists for completeness. Of all
between studies
37 identified tools, the GDG gathered information regarding psychometric properties: validity, reliability, responsiveness
Imprecision* Wide confidence intervals or large p-value; ; few pwp included*, and interpretability, as well as and feasibility to use (Table 1.7)150. Based on these properties, the GDG selected the final
Publication bias Studies or outcomes with expected small or no results not published set of recommended tools.
*most frequent reasons for downgrading
8 9
European Physiotherapy Guideline for Parkinson’s disease
Given the focus of physiotherapy treatment and communication, tools on the activities and participation component of
the ICF are considered preferable. The majority of tools available were developed for the benefit of scientific research and
are focused on use in groups of pwp. The value of these instruments for indication and evaluative purposes in individual
pwp is still unclear and may lead to false security. As a rule of thumb, when used in single pwp, these tools are less
responsive because the measurement error in a single person is larger than it is in groups. Consequently, a single pwp a
change in activity limitations needs to be larger in order to be picked up by the than it needs to be in groups of pwp.
Table 1.7 Selection criteria for measurement tools
Criteria Meaning
Validity Does it measure what it is supposed to measure?
Does it have the same meaning for pwp?
Is it within the scope of physiotherapy for pwp?
Is it linked to the level of limitations in activities domain of the ICF?
Reliability Are results consistent when used in consistent conditions?
Responsiveness & Can it detect change over time?
interpretability Can we assign a qualitative meaning to the (change in) quantitative scores?
Feasibility Do benefits outweigh the burden in terms of costs, time, space and effort?
Is it currently used by (many) physiotherapists?
Is it available in many languages?
1.8 Update of this Guideline

Planned at the latest by 2019. The copyright holder of this Guideline will decide whether the Guideline needs an update. This
depends on the amount and strength of new scientific evidence, changes in barriers in current care or changes in the
organisation of care. New evidence will be appraised conforming methods used for this Guideline by a writing group assigned
by the copyright holders. All participating associations will be offered the possibility to participate in this process. At www.
parkinsonnet.info/euguideline, the users of the Guideline will be invited to share their experience and knowledge.
10
Appendix 14 Table Appendix 14.1 ‘Critical outcomes’, outcomes with an importance-score of 6.5 or above
Grouped outcome Core ICF Tools used in research mean
Graded classes of
area code score
Capacity measure of Gait d Tinetti Gait Assessment 8,8
functional mobility (that is Transfers Timed Get-up and Go
changing body position and Balance Sit to stand time
outcomes
walking) Timed U-turn
Turning in place 360
Standing up & lying down
Ascend and descend stairs
Climbing up & down a flight of stairs
5-step test
All outcomes reported in the CCTs used for this Guideline are grouped on ICF code (Appendix 9) Supine to standing turning time
(Modified) Parkinson Activity Scale
and graded by the GDG for their importance on a scale of 1 (not important at all) to 10 (most Short Physical Performance Battery (SPPB)
Capacity measure of Walking Gait d Walking speed (3 to 24-m walk test; Backward 8,6
important) -1 walking)
Performance measure of Gait d Freezing of Gait Questionnaire 8,3
Walking Freezing of gait diary
(that is gait)
Capacity # # # measure of Balance d Dynamic Gait Index 8,2
Changing and maintaining Timed (single or tandem) stance
body position Functional Reach
(that is balance): DYNAMIC Maximum balance range
Berg Balance Scale
Tinetti Balance Assessment
Number of falls
Movement functions: Gait Gait b Step or Stride length (10, 12 or 24-m walk test) 8,2
pattern -1
Capacity measure of Walking Gait d Walking distance (2- or 6-minute walk) 8,1
-2
Patient-based treatment effect p Goal Attainment Scaling (GAS) 8,1
Patients Specific Index PD
VAS for improvement problem
Patient reported Clinical Global Impression scale (CGI)
of Change
Performance measure of Balance d (Modified) Falls Efficacy Scale (FES) 7,9
Changing and maintaining ABC
body position Parkinson's Disease Falls Risk Score
(that is balance) Latency to falls / near falls
Movement functions: Gait b Cadence 7,7
Gait pattern - 3 Variation of stride length
Quality of life Parkinson’s Disease Questionnaire 39 (PDQ-39) 7,4
Parkinson’s Disease QOL Questionnaire (PDQLQ)
EuroQOL-5D
Sickness Impact Profile (SIP)
Nottingham Health Profile (NHP)
Movement functions: Gait Gait b Step width 7,2
pattern
-2
Performance measure of Physical d Physical Activity Scale for the Elderly (PASE) 6,9
looking after one’s health capacity Phone-FITT
Habitual Physical Activity Questionnaire
Movement functions: Balance b Pull test 6,8
functions of involuntary UPDRS – motor
movement, voluntary UPDRS Posture & Gait score
movement control and muscle
tone
Muscle functions Physical b Muscle strength or power 6,6
capacity
Performance measure of self All d None reported 6,5
care (that is basic ADL)
11 12
Table Appendix 14.2 ‘Non-critical outcomes’ - outcomes with an importance-score lower than 6.5
Grouped outcome Core ICF Tools used in research mean Appendix 15
Overview of excluded
area code score
Composite score for disease All h Short Parkinson Evaluation Scale-SCOPA 5,7
severity Webster Rating Scale
Unified Parkinson’s Disease Rating Scale
CCTs: reasons for exclusion

(UPDRS) total score
Brown’s Disability Scale
Self-Assessment PD Disability Scale (SPDDS)
Mobility of joint functions Physical b Functional axial rotation 5,7
capacity Range of motion
Thoracic kyphosis
Capacity measure of Fine hand use Dexterity d Fugl-Meyer assessment 5,5
and lifting and carrying objects (that Action research arm test (ARAT) Table Appendix 15 Overview of excluded CCTs: reasons for exclusion
is manual activity) Box and block test
Grooved Pegboard Reason for exclusion 1st Author, year
Purdue Pegboard test
Performance # # measure of All d Nottingham Extended ADL Index 5,3 No or insufficient data for ‘critical Bergen 20021 Lee 201113
mobility and domestic life (that is Schwab and England ADL outcomes’ Blackington 20022 Lehman 200514
extended ADL) UPDRS – ADL Burini 20063 Marjama-Lyons 200215
Pain b Visual Analogue Scale 6,3 Byl 20094 Shiba 199916
Cerri 19945 Stallibrass 200217
Acceptability and safety of NA incidence of adverse outcomes 6,2
Cianci 20106 Tamir 200718
drop-outs during study
Dam 19967 Tanaka 200919
number of falls
Ganesan 20108 Purchas 200720
Exercise tolerance functions: Physical b Fatigue Severity Scale (FSS) 5,4 Hass 20069 Troche 201021*
fatigability capacigty Homann 199810 Van Gerpen 201022
Exercise tolerance functions: Physical b Endurance / aerobic capacity 5,3 Inzelberg 200511* Yen 201123
aerobic capacity capacity Max cardiopulmonary exercise test Katsikitis 199612
Metabolic equivalents (MET) Identical to another, included CCT Bridgewater 199624 (identical to Bridgewater 199725)
Global mental functions b Hamilton Depression Rating Scale 4,8 Earhart 201026 (identical to Duncan** 201227)
Geriatric Depression Scale Forkink 199628 (identical to Toole 200029)
Epworth Sleepiness Scale Goodwin 200930 (abstract of Goodwin 201131)
Attitudes to Self Scale Hackney 200932 (identical to other Hackney 200933)
Beck Depression Inventory (BDI) Lim 201034 (identical to Nieuwboer 200735)
Beck Anxiety Inventory (BAI) Müller 199736 (identical to Mohr 199637)
Zung Self-Rating Depression Scale (SDS) Schilling 200838 (identical to Schilling 201039)
Global patient’s mood status (PMS) Type of intervention Chiviacoski 201240 (self-control within treatment, pwp choices)
State-Trait Anxiety Inventory Fiorani 199741 (occupational therapy)
Hospital Anxiety and Depression Scale Formisano 199242 (multidisciplinary rehabilitation: OT, PT, SLT)
Positive and Negative Affect Gauthier 198743 (occupational therapy)
Capacity measure of looking after d Ambulatory activity monitoring 4,7 Gibberd 198144 (multidisciplinary rehabilitation: OT, PT)
one’s health Gobbi 200945 (comparison exercise protocols, different contents &
Specific mental functions b SCOPA-cog 4,7 frequency)
ADAS-cog Guo 200946 (multidisciplinary rehabilitation)
SWM: spatial working memory SRM: spatial Hass 200747 (additive effect of creatine to progressive resistance training)
recognition memory Hurwitz 198948 (nurse-student supervised range of motion exercises)
PRM: pattern recognition memory Modugno 201049 (PT as control intervention: 3 years, 2/wk, 2-3 hrs; N=10)
SOC: stockings of Cambridge Pacchetti 200050 (active music improvisation using instruments and voice)
FAS: verbal fluency for letters Palmer 198651 (intervention: slow stretching versus karate)
CFA: category fluency for Patti 199652 (multidisciplinary rehabilitation)
Wisconsin Card Sorting Test (WCST; executive Reuter 201153 (multidisciplinary rehabilitation)
function) Tickle-Degnen 201054 (multidisciplinary rehabilitation)
Wechsler Adult Intelligence Wade 200355 (multidisciplinary rehabilitation)
Scale III = attention Wells 199956 (osteopathy)
Stroop test White 200957 (multidisciplinary rehabilitation)
Clock drawing Single (day) treatment only Chouza 201158
Capacity # # # measure of balance Balance Posturography (sensory organization test, 4,3 Fok 201259
- STATIC postural sway) Haas 200660
Functions of the respiratory system Physical b Inspiratory muscle strength 4,0 King 200961
capacity Inspiratory muscle endurance *no outcomes for respiration were selected as ‘critical’
VO2peak
Functions related to the digestive b Safety: Penetration–aspiration score 2,8
system: swallowing Swallowing timing
13 14
Appendix 16 Table Appendix 16
Included measurement tools*

Measurement tools considered for recommendation
Excluded measurement tools
Measurement tools considered 1. 10 Meter Walk (10MW)

2. Activities Balance Confidence (ABC) Scale
3. Berg Balance Scale (BBS)
a. 2-Minute step test
b. Balance Evaluation Systems Test (BESTest)
c. Freezing of Gait Questionnaire (FOGQ)
for recommendation
4. Borg Scale 6-20 d. Functional Reach (FR)
5. Dynamic Gait Index (DGI) e. Global Perceived Effect (GPE)
6. Falls Efficacy Scale International (FES-I) f. LASA Physical Activity Questionnaire (LAPAQ)
7. Five Times Sit-to-Stand (FTSTS) g. Lindop Scale
8. Functional Gait Assessment (FGA) h. Movement Disorder Society’s (MDS) revision of the UPDRS (MDS-UPDRS)
9. Goal Attainment Scaling (GAS) – goals evaluation form i. Nine Hole Peg Test
The following pages provide psychometric properties and feasibility for use in pwp of all measurement tools 10. History of falling j. Parkinson Activity Scale (PAS)
11. Mini Balance Evaluation Systems Test (Mini-BESTest) k. Parkinson’s Disease Questionnaire (PDQ-39)
that the GDG considered for recommendation in this Guideline. In alphabetical order: first the included, then 12. Modified Parkinson Activity Scale (M-PAS) l. PHONE FITT
13. New Freezing of Gait Questionnaire (NFOG-Q) m. Physical Activity Scale for the Elderly (PASE)
the excluded tools. 14. Patients Specific Index PD (PSI-PD) n. Pull Test
15. Push and Release Test (P&R Test) o. Purdue Pegboard Test
16. Rapid Turns test p. Survey of Activities and Fear of Falling in the Elderly (SAFFE)
17. Six Minute Walk Distance (6MWD) q. Tinetti Performance Oriented Mobility Assessment (POMA) , Gait (G) and Balance (B)
18. Timed Get-up and Go (TUG) r. Unified Parkinson’s Disease Rating Scale (UPDRS)
s. WALK-12 Questionnaire
*Chapter 5 supports decision-taking towards careful selection of

appropriate tools in each unique pwp.
Note: No single pwp requires the use of all 18 tools.
15 16
Appendix 16. Abbreviations and explanation of terminology 1. 10 Meter Walk (10MW)
AUC Area Under the ROC Curve: accuracy to discriminate; 0 to 100, with cut-off scores >0.9, excellent; 0.70-0.90, adequate; <0.70, poor62
ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Capacity (ICF) Executing tasks in a standard environment, indicating the highest probable level of functioning in a given domain at a given moment
Activities & Seconds required to walk 10 Concurrent validity UPDRS Excellent test-retest H&Y1-4: MDC95 for Assessment time 5 min; Required materials:
Ceiling effect The tool is not sensitive enough to assess good functioning people as many people score the highest score: the tool items may be too easy Participation: meter: comfortable and fast ADL, r=0.4164; comfortable reliability: comfortable comfortable speed 0.18 m/s stopwatch, marked 12m pathway (10m plus
Changing and maintaining body position Balance Capacity measure of walking speed (m/s); speed accounted for 23% speed, ICC0.96; fast speed, (mean baseline 1.16 m/s); 2m at end for deceleration); Current use
Walking assistive devices can be variance UPDRS motor & total ICC0.9766 ; Good test-retest MDC95 for fast speed 0.25 >35%
Concurrent validity Measure for correlation of the tool to another (validated) tool, measured at (approximately) the same time, using Spearman’s or Pearson’s rho (r). A used;valid as 6MWD at scores64; Good convergent reliability comfortable m/s (mean baseline 1.47 Benefits: assesses velocity, step and stride
form of criterion validity (also predictive validity) home validity¬ comfortable speed speed: ICC0.8767; walking m/s)66; H&Y 1-3: MDC95 length: useful for cueing. Drawbacks: large
with Posturo-Locomotor- speed, ICC0.8, and step 0.19m/s68 space required; different methods of
Convergent validity Degree to which the scores of tools, which theoretically are the same, relate. A form of construct validity; see also discriminative validity Manual Test scores (r=0.76)65 frequency ICC 0.8068 conducting the 10MW are described
Cronbach’s α Cronbach’s alpha: coefficient of internal consistency of results across items within the test; cut-off scores: α ≥ 0.9 excellent, ≥ 0.8 good, ≥0.7
acceptable, ≥0.6 questionable, ≥0.5 poor, and < 0.5 unacceptable.
Current use Based on results of the European Guideline’ survey: low=<10%; intermediate=<10-35%, high=>35% 2. Activities Balance Confidence (ABC) Scale
Discriminative validity Degrees to which scores of tools that theoretically are different can be discriminated. A form of construct validity; see also convergent validity
Floor effect Tool not sensitive enough to assess badly functioning people as many people score the lowest score: the tool items may be too difficult
ICC Intraclass correlation coefficient, measure for intra-rater (test-retest) and inter-rater reliability; cut-off scores: > 0.89, excellent; 0.80-0.89, good; 0.70- Activities & Interview or self-report Good convergent validity: TUG r=-0.44; walking sub-scale of NUDS Moderate to H&Y 1-4, mean Assessment time 15
0.79 moderate; <0.69, poor Participation: questionnaire, level of r=-0.48, p= 0.02); item 1 (mobility) of the PD Quest-Short Form r=0.5170 excellent test-retest baseline 70%: min; No materials or
Performance self-confidence: 16 Concurrent validity: BESTest: r=0.63671; BBS r=0.64; BESTest r=0.79; HY reliability: MDC95 13% 66 costs materials;
ICF International Classification of Functioning, Disability and Health
measure of ambulation activities, r=0.59; UPDRS motor r=0.52; UPDRS Total r=0.7372; 6MWD R2=17.1%73 ICC=0.94; H&Y H&Y 1-3, mean Current use 10-35%
k Weighted Kappa: agreement beyond that what be expected by chance; cut-off scores: ≤ 0=no agreement; 0.01-0.20=slight; 0.21-0.40=fair; Changing & 11-point ordinal scale: Adequate discriminative validity: 1) fallers vs non-fallers: mean HY3, ABC 1-466; ICC=0.79; baseline 91%: MDC95
0.41-0.60=moderate; 0.61-0.80=substantial; 0.81-1.0 almost perfect 63 maintaining body 0% to 100% (complete < 76% (AUC 0.76, sens 0.84, spec 0.62)74; mean HY 2.8, ABC ≤80% (OR H&Y 1-370 11.12 %70
position confidence). Total score: 0.06)73; ABC <69% (AUC 0.82, sens 0.93, spec 0.67)75 ; 2) pwp (HY 1-3) SEM= 4.0170
LOA Limits of agreement: mean difference and 95% LOA between two measurements: 95% of differences between two measurements
mean69 vs controls: sens 0.86, spec 0.5276; 3) between HY stages: HY1 (baseline
MCIC / MCID Minimal Clinical Important Change / Difference: that are meaningful to patients 94.9 %) vs HY3 (baseline 81.0 %)70; HY1.8 vs HY3.577
MDC Minimal Detectable Changes: smallest minimal change falling outside the measurement error
Performance (ICF) Executing tasks in the current environment, describing what an individual does in his or her current environment 3. Berg Balance Scale (BBS)
Predictive validity The extent to which the tool predicts the future score on another (validated) tool. A form of criterion validity (also concurrent validity)
r Correlation coefficient, with cut-off scores >0.6, excellent; 0.30-0.60, adequate; <0.30, poor; see concurrent and predictive validity
ROC Receiver operating characteristic: a graph showing the sensitivity (y-axis) versus 1-specificity (x -axis) for all possible cut-off points Activities & Observation Moderate to good concurrent validity: BESTest r=0.87, UPDRS ADL r=-0.81; Test-retest good to H&Y 1-3, baseline Assessment time 20 min;
Participation: balance FGA r=0.78;; TUG r=0.78; Self-selected walking speed r= 0.73; FOF r=0.69; excellent: ICC=0.9466; 53.77/56: SDD 2.84 Required materials: ruler, two
SDDdiff Smallest detectable difference between two raters (1.96 x (√2 x error): when a patient is scored by two different raters, and the scores differ > SDD,
Capacity performance ABC r=0.64; Fast walking speed r=0.64; UPDRS motor r=0.51, 0.58 and 0.71; 0.8072; 0.8768 points (5%)68 chairs with(out) arms,
the patient is likely to have improved/ deteriorated
measure of 14 items UPDRS ADL r=-0.64; H&Y r=0.45, r=0.61 and 0,63; Modified Schwab & England Inter-rater adequate H&Y 1-4, mean stopwatch; item to pick up;
SEM Standard error of measurement: standard deviation of sampling distribution, precision estimate of distribution around the “real” score Changing & involving (ADL) r=0.55 and 0.71; PDQ-39 r=0.61; Functional Reach r=0.50 64;66;72;78-81 to excellent: baseline 50/56: step or footstool; Current use
Sensitivity Proportion of patients with the problem (such as falls, balance problems) who test positive maintaining sitting, Adequate discrimination fallers vs non-fallers: HY2-3, BBS ≤ 54 points (sens ICC=0.9572; 0.7468; MDC95 5 points66 >35%
body standing and 0.79, spec 0.74)82; HY mean 2.3 BBS≤51 sens 0.74 spec 0.7783; HY3, BBS<44 0.8487 Benefits: widely used
Specificity Proportion of patients without the problem who test negative position changes in (AUC 0.85, sens 0.68, spec 0.96)74; HY1-4, BBS≤47 (AUC 0.79, sens 0.72, spec Intra/inter-rater Drawbacks: mainly static
position 0.7572; HY1-4, BBS≤45 (sens 0.64, spec 0.83)84; mean HY2.4, BBS≤47 6 mnths excellent: ICC= 0.9988 balance; ceiling effect (absence
ordinal: 0 AUC 0.87 (sens 0.79, spec 0.86); 12 mnths AUC 0.68 (sens 0.46, spec 0.81)85; Adequate internal pwp specific impairments:
(worst) to 4, HY1-2 AUC 0.61 (sens .65, spec .51)86; HY1-2 vs HY3-4 AUC 0.84, cut-off ≥52 consistency: α=0.8666 freezing, multi tasking);
max 56 (sens .77, spec .74)83 ; Increases with disease progression77; HY1-2 vs 3-4: to 0.9287 identifies fallers less accurate
BBS<52 AUC 0.84 (sens 0.77, spec 0.74)83 than than (Mini-)BESTest72;85
17 18
4. Borg Scale 6-20 7. Five Times Sit-to-Stand (FTSTS)
ICF Scoring Validity Reliability Responsiveness Feasibility 1) ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Body functions: Self-report score for perceived Unknown in pwp Unknown in pwp Note: Not applicable: Assessment time 5 min; No materials or costs; Current use Activities & Balance mea- Discriminative validity fallers vs non-fallers, H&Y Excellent Inter- Unknown in pwp Assessment time 2 min; Required materials : stop-
Exercise exertion (physical activity intensity Borg Scale 6-20 is used 10-35% Participation: sure: time nee- 1-4, >16s (AUC 0.77, sens 0.75, spec 0.68)94 rater reliability: watch, 43cm chair; Current use unknown
tolerance level): 6 (no exertion at all) to 20 to prescribe and monitor Benefits: widely used in pwp to support exercising at the Capacity measure ded for 5 times Moderate to good concurrent validity: BBS ICC=0.99
functions (maximal exertion).89 Can be exercise intensity, not for desired intensity of Changing & sit to stand r=0.71, 6MWDT r=-0.60, ABC r=0.5494 Moderate test- Benefits: Quick measure for balance & leg strength;
used during 6MWD and (other) evaluative purposes Drawbacks: no psychometric data available for pwp maintaining body retest reliability Drawbacks: not widely used yet; not for evaluation;
exercises position ICC=0.7694 Drawbacks: floor effect, pwp may be unable to per-
form without using the upper extremities94
NOTE: In healthy adults, the BORG Scale 6-20 correlates moderate to good with physiological measures: heart rate (r = 0.62), blood lactate (r = 0.57), Vo2max (r = 0.64) , ventilation (r = 0.61) and
respiration (r = 0.72)90; In healthy adults, Borg scores multiplied by 10 indicate heart rate
8. Functional Gait Assessment (FGA)
5. Dynamic Gait Index (DGI)
Activities & Observation of balan- Good concurrent validity with BBS Excellent test-retest Unknown in pwp Assessment time 10 min; Required materials: shoe
Activities & Observation balance when Adequate discriminative Good test-retest H&Y 1-3, mean baseline Assessment time 10 min; Required materials: shoe box, 2 Participation: ce when performing (r= 0.78)72 reliability: ICC=0.9172 box, 2 cones, stairs, 6m walkway, 0.5 m wide; Current
Participation: performing gait related activities validity fallers vs non- reliability: 21.6: MCD 2.9 points, cones, stairs, 6m walkway, 0.5 m wide; Current use 10-35% Capacity mea- gait related activities: Discriminative validity fallers vs non- Excellent inter-rater use: unknown
Capacity 8 items, 4-point ordinal scale: 0 fallers: HY 2-3, DGI ≤ 22 = ICC=0.8491 (13.3% change)91 Benefits: better discriminative validity for fallers vs non-fallers sure of Changing & 10 items, 4-point or- fallers: H&Y mean 2.5 FGA ≤15/30 reliability: ICC=0.9372
measure of (lowest level functioning) to 3. at risk (sens 0.89, spec No systematic than TUG and BBS74;84;92; can be combined with Functional maintaining body dinal scale: 0 (lowest (AUC 0.80, sens 0.72)72; H&Y 1.5-4, Benefits: in older people, higher discriminative validity
Changing & Total score max 24 0.48)82; HY3, DGI < 19 = at bias: LOA 2.9 to Gait Assessment (FGA): Drawback: does not include backward position level functioning) to 3 AUC 0.81 (ON) to 0.89 (OFF)95; HY for fallers, as well as more reliable than BBS72; can
maintaining risk (AUC 0.76, sens 0.68, -3.0 points91 walk (as FGA does); need for specific material mean 2.4: 6 mnths AUC 0.80 (sens be combined with DGI; includes backward walking.
body position spec 0.71)74; HY1-4, DGI 0.64 spec 0.81) & 12 mnths AUC 0.70 Drawbacks: not widely used yet; identifies fallers less
≤19 (sens 0.64, spec 0.8584 (sens 0.46, spec 0.81)85 accurate than (Mini-)BESTest85
6. Falls Efficacy Scale International (FES-I) NOTE: Equates to the DGI: exclusion of walking around obstacles; addition of 3 sensory integration tasks: gait with narrow base of support, ambulating backwards, gait with eyes closed

9. Goal Attainment Scaling (GAS) – goals evaluation form
Activities & FES-I: 16-item questionnaire on Unknown in pwp Unknown in pwp Unknown in pwp Assessment time 10 min; No materials or costs; Current use
Participation: self-confidence (efficacy) to avoid 10-35% ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Performance falling administered. Interview or Benefits: available in many, validated languages at
measure of self-report. 4-point ordinal scale: www.profane.eu.org; preferred in current scientific studies Patient-centred Setting SMART goals with Face validity: Unknown in Unknown in pwp Assessment time describing SMART goals 10 min; scoring level reached (eva-
Changing & 1 to 4 (highest fear to fall). Total evaluating physiotherapy for pwp; provides better insight (more goals and treat- pwp (and carer); each goal 5 patient decides pwp luation) 1 min; No materials or costs; Current use <10%
maintaining score range 16 to 64. activities) than Short FES-I ment effects in levels of outcome: optimum, upon goals, what
body position all ICF compo- 2 above, 2 below. Sum score, to evaluate Benefits: supports setting SMART goals
nents independent of number of Furthermore,
goals, max 50 (all goals met) unknown in pwp Drawbacks: may be time-consuming to describe a goal on 5 levels; especially
NOTE: of the original FES, no psychometric properties in pwp are available; a Swedish version (FES(S)) differs in number of items and scoring options, suitable for the Swedish population; FES(S):
when >1 goal is chosen
Correlations with SAFFE r=-0.74; physical functioning (SF-36) r=0.66; fast gait speed, r=0.63; TUG r=0.61; UPDRS Parts II r=-0.58) and III r=-0.46; comfortable gait speed, r=0.30; disease duration,
r=-0.28; and age r=-0.07.93; Good test-retest reliability, ICC=0.87; SEM=12.3 points; Discriminative validity: lower scores females vs men and for pwp reporting previous falls, FOF or unsteadiness
versus those not who do not93 NOTE: There is strong evidence for the reliability, validity and sensitivity of the GAS in physical and neurological rehabilitation in general96; In (frail) elderly, the GAS has adequate concurrent validity
with ADL measures (r = 0.45 to 0.59)96-98 Cognitive impairments may reduce its feasibility, validity, reliability and responsiveness99; GAS can detect clinically relevant change in geriatric day hospital
care100 and is more sensitive than standardised ADL measures97
19 20
10. History of falling 13. New Freezing of Gait Questionnaire (NFOG-Q)
Activities & Questionnaire: inter- Face validity: based on optimal time span for recall (in Unknown in Unknown in Assessment time 5-15 min; No materials or costs; Activities & Clinician-administered tool assessing Poor concurrent Good reliability between pwp Unknown in pwp Assessment time 10 min; Required materials: video;
Participation: view or self-report, elderly)101; specific vocabulary to optimise recall of falls in pwp pwp Current use 10-35% Participation: clinical aspects of freezing of gait (FOG) validity with time and carers, ICC=0.78; Current use: unknown
Performance retrospective number pwp102 Performance and influence on QOL: three parts (9 spent frozen during Reliability pre-post video
measure of of (near) falls, circum- Retrospective falls report good discriminative validity to Benefits: past falls best predictor of future falls, measure of items, total score range 0-28): Part I, di- TUG tasks (r=0.35) good for pwp (ICC=0.88) Benefits: a golden standard to assess FOG lacks;
Changing & stances & causes; 2 to identify pwp at fall risk: ≥1 fall in previous year (sens 77%, designed for pwp Walking chotomous, to exclude patients without or number of FOG and excellent for carers watching the video improves scoring FOG duration;
maintaining 13 questions spec 60%), ≥2 falls in previous year (sens 68%, spec 81%) FOG; Part II (items 2-6, score range events (r=0.30).112; (ICC=0.97)113 items 2-6 provide a structured means to gain insight
body position 103
; a fall in the previous year OR 4.0 104 to OR 5.0105 Drawbacks: retrospective, thus under reporting 0-19): FOG duration & frequency; Part for freezers only High internal consistency: into the circumstances of freezing and are therefore
III: impact of FOQ on daily life (items with H&Y (r=0.30) Cronbach’s α 0.84, equal included in the PIF
7-9; score range 0-9)111 and falling (r=0.35113) loading factors113
11. Mini Balance Evaluation Systems Test (Mini-BESTest) Drawbacks: usefulness for clinical practice unknown
ICF Scoring Validity Reliability Responsiveness Feasibility 1) NOTE: Compared to the original, 6-item FOGQ, the NFOG-Q has extra the video explaining freezing, Part I (1 item), item 2 of Part II (to assess overall FOG, frequency only) and Part III; the 2 items for
gait were removed
Activities & Participation: Observation Good concurrent validity with BESTest r=0.96106; Mostly HY2-3: Unknown in pwp Assessment time 15 min; Required materials:
Capacity measure of balance in 14 BBS, r=0.79, and UPDRS, r= −0.5183 good test- shoe box, 2 cones, stairs, stopwatch, 0.5m
Changing & maintaining activities; 3 Good discriminative validity fallers vs non fallers: retest reliability, wide walkway; Current use unknown 14. Patients Specific Index PD (PSI-PD)
body position point ordi- AUC 0.84106; average score 27% difference; cut-off ICC=0.92106 Benefits: no ceiling effect (as with the BBS);
AND nal scale: 0 scores: 20/32 (63%) (sens 0.88, spec 0.78), 23/32 Excellent inter- discriminates fallers vs non fallers better than ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Body functions: (severe) to 2 (72%) (sens 0.96, spec 0.47)106 ; 19/30 (sens 0.79, rater reliability, FGA and BBS85; also available in Portuguese
Involuntary movement (normal), max spec 0.67 AUC 0.75)107; HY1-2 vs HY3-4 AUC=0.91; ICC=0.91106 (Brazil), Greek and Japanse: www.bestest.us. Patient-centred Questionnaire: interview Good content vali- High test-retest agreement for domains (core Unknown in pwp Assessment time 10 min; No materials or
reaction functions score 28 ≤20 HY mean 2.3 (sens .89; spec .81)83; H≤20 HY Drawback: does not include backward walk (as problems in all & (partly) self-report to dity: predefined list of areas: 74%-82%), but with low Kappa values costs; Current use <10%
mean 2.4: 6 mnths AUC 0.87 (sens 0.86 spec 0.78) FGA does); identifies fallers more accurate than ICF components identify, prioritise and impairments based on (0.43 to 0.60) as positive and negative outco-
& 12 mnths AUC 0.77 (sens 0.62, spec 0.74)85 BBS and FGA85 rate severity of patient the 2004 KNGF Guide- mes were not equally distributed116 Benefits: provides insight into quality of perfor-
relevant limitations line114-116 mance, targets for treatment;
Drawbacks: assistance required for ranking
Note: Swedish translated version Correlations with BBS r=0.94, TUG r=-0.81 and FES(S) r=0.26108
NOTE: In this Guideline, the items of this tool are included in the Pre-assessment Information Form (PIF)
12. Modified Parkinson Activity Scale (M-PAS)
ICF Scoring Validity Reliability Responsiveness Feasibility 1) 15. Push and Release Test (P&R Test)
Activities & 14-item observation Face validity: Excellent test-retest reliability Total score: ICC=0.93 in Unknown Assessment time 30 min; Required ma- ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Participation: performance functional based on core OFF, ICC=0.81 in ON; poor to excellent test-retest relia- terials: chair, cup, water, bed, bed cover;
Capacity activities: chair transfer areas and limita- bility sub scores in ON and OFF, range ICC=0.41-0.91109 Current use 10-35% Body functi- Measure reactions to external perturba- Good convergent validity with Good inter- Unknown in pwp Assessment time: 2 min; No materials or costs;
measure of (2 items); gait akinesia tions in activities Good to excellent inter-rater reliability (Kappa 0.86 to ons: tion: 1 unexpected trial: clinician stands self-report history of falls (r=0.6)117 rater reliability: Current use unknown
functional (6 items); bed mobility described in 0.98)109 Benefits: supportive for gaining insight Involuntary behind patient, hands against patient’s Discriminative validity fallers vs ICC=0.84117 Benefits: Compared to Pull Test: more gentle &
mobility (that is (6 items).109 Quantitative evidence-based Adequate internal consistency (PAS total score Cron- into quality of movement specific for movement scapulae; active or passive lean back; non-fallers: OFF phase sens P&R safer in frail pwp, more sensitive in pwp with low
changing body and qualitative scoring physiotherapy bach’s α 0.85; chair transfer 0.76; gait akinesia 0.75; physiotherapy in pwp; Drawbacks: can- reaction suddenly removes hands; Test 89% vs Pull Test 69%; ON balance confidence (but less so for those with
position and on an ordinal scale guidelines for bed mobility with/without covers 0.79/0.89)109 not be used for evaluation functions 5 point ordinal scale: 0 (recovers inde- phase sens P&R Test 75% vs Pull high balance confidence), higher inter-rater relia-
walking) from 4 (best) to 0 (im- pwp109;110 pendently with 1 step of normal length Test 69%; OFF phase spec P&R bility (due to more consistent forces applied) and
possible or dependent and width) to 4 (falls without attempting Test 85% vs Pull Test 98%; ON higher sensitivity than in the off phase (compara-
on help) a step or unable to stand without as- phase spec P&R Test 98% vs Pull ble in the on phase);
sistance Test 83%118 Drawbacks: unknown by neurologists
21 22
16. Rapid turns test a. 2-Minute step test
ICF Scoring Validity Reliability Responsiveness Feasibility 1 ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Body func- Dichotomous measure to as- Sensitivity to provoke freezing 0.65; Unknown Not applicable: Assessment time 2 min; No materials or costs; Current use: Body func- Measure for aerobic endurance (alternative to In HY1-3: due to Unknown in Unknown in pwp Assessment time <5 min; Required materials: tape, stopwatch, wall;
tions: sess freezing: pwp are asked sensitivity entire battery of three trials in pwp used for the unknown tions: 6MWDT): number of times knees are raised fatigue 2min into pwp Current use unknown
Gait to repeatedly make rapid 360° (normal speed, fast speed, and with assessment of Exercise up to level of tape on wall in 2 min; in case of 1 min test, mean Benefits: easy to administer; Drawbacks: not validated for pwp (only
pattern narrow turns from standstill, on dual tasking) & turning variants (180° freezing only Benefits: easy and best test available to provoke freezing tolerance balance problems hands can be placed on score 23 steps131 high test-retest reliability and discriminative validity in community
functions the spot, in both directions; if vs. 360° turns; both directions, wide functions the wall130 dwelling elderly130;132)
required add dual task and narrow; slow and fast) 0.74119 Drawback: does not always provoke freezing, dual tasking may
NOTE: Alternative: 1 min stairs step test: safe and feasible test for lung problems, similar info to 6MWD
still need to be added (M-PAS Gait Akinesia)
b. Balance Evaluation Systems Test (BESTest)

17. Six-Minute Walk Distance (6MWD)
Activities & Partici- Observation of balance Good concurrent validity with Mini- Mostly HY2-3 Unknown in pwp Assessment time 35 min; Required materials:
Activities & Distance in meters walked in 6 Good convergent validity: regular Excellent HY1-4, mean Assessment time: 10 min; Required materials: stop- pation: during 36 activities, BESTest r=0.96106; ABC (r=0.76), BBS Good test-retest reliability shoe box, 2 cones, stairs, stopwatch, 0.5m
Participation: minutes, at fast speed, as a measure physical activity r =0.56, R2 =0.32122 ; test-retest baseline 316m: watch; ≥ 30m, flat, straight hard surface (indoors or Capacity measure of such as sit to stand and (r=0.87), FGA (r=0.88)72 ICC=0.8872; ICC=0.88106; wide walkway; Current use unknown
Capacity mea- for functional fitness.120;121 H&Y r=0.38; BBS r=0.64; TUG r=0.64; reliability: MDC95 82 m66 outdoors), marked every 3m, with a bright coloured Changing & maintai- stand 1 leg (from BBS), Good discriminative validity fallers Inter-rater reliability
sure of Walking Assistive devices can be used if kept FOGQ r=0.43 and UPDRS r=0.27123 ; ICC=0.9666, tape at the starting point; 2 cones to mark the turna- ning body position. challenged gait tasks vs non fallers, AUC 0.84; average adequate for section II, Benefits: discriminates fallers vs non fallers
consistent from test to test; pwp score accounted for 43% of variance 0.93125, 0.9567 round points; pen, paper; Current use >35% AND (from TUG, DGI), FR and score 19% difference; cut-off scores: ICC=0.79 and good better than FGA and BBS72 ; Drawbacks: time
should not exercise vigorously 2hr UPDRS motor and UPDRS total64 Benefits: can be used as treatment; Drawbacks: Body functions: dual-task items: 3 point 69% (sens=0.84, spec=0.76); 84% for other sections consuming and complex; both activities &
before the test and relax 10 min on Decreases with disease duration: large space required and large variation in ‘average’ Involuntary movement ordinal scale: 0 (severe) (sens=1.0, spec=0.39)106 ; AUC 0.85, ICC=0.91106; excellent for body function included in one balance score,
a chair before starting the 6MWD 173m HY3 vs HY1–1.5124 Impaired distances : 300-600m66;67;122;126;127 ; learning effect reaction functions to 2 (normal), max 108 cut-off score 69%72 total ICC=0.9672 difficult to interpret; not widely used yet
(such as during history taking) balance & fall risk influence 6MWD123 noted in COPD (improvement through practice 6%)120
NOTE: A 2MWD is insufficient in picking up the endurance problems in earlier stage pwp124
c. Freezing of Gait Questionnaire (FOGQ)
18. Timed Get-up and Go (TUG) ICF Scoring Validity Reliability Responsiveness Feasibility 1)
ICF Scoring Validity Reliability Responsiveness Feasibility 1) Activities & Clinician-adminis- Adequate discriminative validity fallers vs Good test–retest relia- Unknown in pwp Assessment time 5 min; No materials or costs; Current
Participation: tered question- non-fallers: AUC .0.73 (sens 0.75; spec 0.59)86; bility (10wks different): use 10-35%
Activities & Parti- Time (s) to: Good convergent validity: BBS, r=-0,78, fast gait speed, Poor to good test-retest H&Y 1-4, mean baseline Assessment time 5 min; Performance naire assessing accuracy 65%133 ICC=0.84134;
cipation: rise from arm r=-0.69; comfortable gait speed, r=-0.67; UPDRS total, reliability: ICC=0.8566; 15 s: MDC95 11 s66 Required materials: measure of clinical aspects Adequate concurrent validity with UPDRS Good inter-rater relia- Benefits: Item 3 (‘Do you feel that your feet get glued to
Capacity mea- chair, walk r=0.5079; H&Y, r=0.75128 ICC=0.8091; ICC=0.6970 H&Y 1-3, mean baseline stopwatch, chair, track mark; Cur- Walking of freezing of gait ADL (r=0.42), walking capacity (r=0.41), ADL bility: ICC=0.84135; the floor while walking, making a turn or when trying to
sure of functional (3m), turn Adequate discriminative validity fallers vs non-fallers, Excellent inter rater relia- 10,6 s: MDC95 4,85 s70 rent use >35% (4 items) and gait (r=0.45)64; UPDRS ADL (r=0.43), UPDRS motor Good to excellent initiate walking (freezing)?) is associated with frequency
mobility (that is and sit down at risk: HY 2-3, TUG ≥ 7.95s (sens 0.93, spec 0.30)82; bility experienced PTs and H&Y 1-4, mean baseline (2 items); 5-point (r=0.40)111; correlations, better in off than on internal consistency : of freezing:’112;134;138 and more sensitive in detecting
changing body to the chair; HY1-4, TUG ≥ 8.5s (sens 0.68, spec 0.53)84; H&Y 1.5-4: inexperienced PTs in ON 9.88 s: MDC 0.67 s88 Benefits: well known, easy to ad- ordinal scale: phase: UPDRS ADL (off r=0.66; r=0.40), UPDRS α 0.89 to 0.96134;136 freezers than UPDRS item 14 (85.9% vs. 44.1%)134
position and wal- mobility, AUC 0.68 (ON) to 0.80 (OFF), More accurate in OFF95; phase, ICC=0.99; good in H&Y 1-3, mean baseline minister; add TUGcog and TUGman 0 (absence of motor (off r=0.49, on r=0.28), and “freezing FOGQ(S) Excellent Drawbacks: contains general gait items only, reducing
king) balance, wal- HY mean 2.8, TUG >16s (OR 3.86)73; early stage PD inexperienced PTs in OFF 11.8s: MDC 3.5 s91 for dual tasks; symptoms) to 4 when walking” (off r=0.74, on r=0.43)134 reliability, ICC=0.93137 its FOG-specificity134
king ability, (AUC 0.65. sens 0.69; spec 0.6286 ; Score increase with phase ICC=0.87129 H&Y 1-3, mean baseline Drawbacks: treatment goal often
fall risk disease severity: 2.5sec difference HY3 vs HY1-1.5124 SEM= 1.75 s70 unknown: SDD 1.6368 safety, not velocity; not for pwp
NOTE: Swedish, self-administered version, FOGQ(S): Higher median scores for fallers than non-fallers (12.5 vs 5.0; n=37)139 , also on the self-administered from (8 vs 2; n=225)137; Adequate concur-
with walking aids
rent validity with UPDRS part II (ADL), UPDRS item 14 (freezing), and HY (r=0.65-0.66), UPDRS items 32-35 (dyskinesia) and 36-39 (motor fluctuations) (r=0.62); UPDRS motor (r=0.59), FES (r=0.59),
UPDRS items 15 (walking) (r=0.56), 13 (falling not related to freezing) (r=0.55) and 29 (gait) (r=0.54), TUG (r=0.40)139 Excellent correlation between clinician-administered and self-administered versions
(ICC 0.91). Correlations were higher in the self-administered form for UPDRS 14 (0.76) and FES (-0.74)137
23 24
d. Functional Reach (FR) g. Lindop Scale
Activities & Measuring forward Correlation with UPDRS ADL r=-0.5264 Poor to excellent test-retest HY1-4, mean baseline Assessment time 5 min; Required Activities & Partici- Observation perfor- Good face validity: Inter-rater reliability: LOA total score Unknown in pwp Assessment time 20 min; Required materials: stop-
Participation: reach while standing Poor to adequate discriminative va- reliability: in pwp with fall his- 21 cm: MDC 9 cm66; materials: corner, duct tape, yard- pation: mance functional mobi- covers core areas (mean difference) 0.041145 watch, chair; track mark, bed; Current use <10%
Capacity in a fixed position: lidity fallers vs non-fallers: HY2-3, tory ICC=0.93; in pwp without fall HY 1-3: SDD 11.568 stick mounted horizontal to the wall; Capacity measure lity (6 gait; 4 bed) alike KNGF Guide- Agreement & between raters 82% to
measure of performance: Three FR≤ 31.75cm = at risk (sens 0.86, spec history ICC=0.42142; ICC=0.7366; MDC: 4cm for pwp with Current use high of functional mo- TUG and PAS; line115;145 100% for all 10 items 145 Benefits: specifically designed for physiotherapy for
Changing & trials are done and 0.52)82; HY1-4, FR ≤19 (sens 0.77, spec ICC=0.8467 history of falls; 8cm for bility (that is chan- 4 point ordinal scale Moderate con- Adequate internal consistency: Cron- pwp; Drawbacks: comparable to M-PAS, but less
maintaining the average of the 0.6584;<25.4cm (sens 30%, spec 92%141; Poor inter rater reliability: pwp without history of Benefits: widely used, easy to admi- ging body position based on seconds or current validity bach’s α=0.86145 established data on psychometric properties and less
body position last two is noted140 AUC 0.52 (sens 0.52; spec 0.53)86 fallers ICC=0.6468 falls; general 12cm68;142 nister and walking) number of steps: UPDRS-motor, detailed qualitative scoring options
mean (sd) = 23.11 (8.12)cm vs non-fallers Moderate intra rater reliability: 0 (worst)-3 r=0.67145
mean (sd) = 31.70 (5.61) cm82 ICC=0.7468 Drawbacks: questionable reliability
h. Movement Disorder Society’s (MDS) revision of the UPDRS (MDS-UPDRS)

e. Global Perceived Effect (GPE)
Composite Observation & (Part I & Good to excellent concurrent validity: Adequate to good Unknown in pwp Assessment time: 30 min (≤10min for interview Part I, 15min
Patient-centred Questionnaire: interview Unknown in pwp Unknown in Unknown in pwp Assessment time 1 min; No materials or costs; ; Current use <10% score for II) patient report, mainly with original UPDRS AUC 0.99146; internal consis- for part III. Motor and 5 min part IV); Costs: training and certi-
treatment effects or self-report of perceived pwp disease functions: Part I, non- Total score, r=0.96; Part I, r=0.76; tency: Cronbach’s fication required: free for MDS members (membership health
in all ICF compo- treated effect. 1 item, score: Benefits: easy to administer severity motor experiences of Part II, r=0.92; Part III, r=0.96; Part α Parts I & IV professionals =$100; non-members: $250 USD); Required
nents 1 (worse than ever) to 7 daily living; Part II, motor IV (items 32–39: dyskinesias & motor 0.79, Part II 0.90, materials: paper, chair, app; Current use unknown
(greatly improved) Drawbacks: no psychometric data available for pwp; scores are strongly influ- experiences of daily fluctuations on UDPRS vs. total Part Part III 0.93147;
enced by current status: do transition ratings truly reflect change? living; Part III, motor exa- IV MDS-UPDRS), r=0.89147; Part I, Part I 0.85148 Benefits: see UPDRS; non-English translations ongoing
mination; Part IV, motor r=0.81; validated non-motor scales
complications (HADS, SCOPA-COG), r=0.72-0.89148 Drawbacks: see UPDRS; not widely used yet
f. LASA Physical Activity Questionnaire (LAPAQ)
ICF Scoring Validity Reliability Responsiveness Feasibility 1) i. Nine Hole Peg Test
Activities & Questionnaire: Discriminative validity: Unknown in pwp Unknown in pwp Assessment time 30 min; No materials or costs; Current use: <10% ICF Scoring Validity Reliability Responsiveness Feasibility 1)
Participation: interview or self- decreases with age (-3% for
Performance report to gain in- each year) and with disease Benefits: time-consuming; Drawbacks: no reliability and responsiveness Activities & Partici- Time (s) to complete Good sensitivity Good to excellent test-retest MDC 2.6s domi- Assessment time: 5 min; Costs: need to buy the test or can
measure of sight into level of severity (-3% for each point known for pwp (in community dwelling elderly, good convergent validity pation: task: visuomotor con- to detect motor reliability: dominant ICC-dominant hand; 1.3s non be made (time consuming) assuring standardised specificati-
physical ac- physical activity on the UPDRS)143 with physical activity and predictive validity for time spent daily on physi- Performance mea- trol, fingertip pinch, dysfunction in nant hand 0.88; ICC non-domi- dominant hand ons152
tivity cal activity144) sure of carrying, and release149 the early sta- nant hand ICC 0.91151 Required materials: peg test, stopwatch;
moving and hand- ges150 Current use: unknown
ling objects SEM 1.02s dominant hand
(average time to complete Benefits: easy to administer; can be used for evaluation. Draw-
31.4s); 0.82s non dominant backs: gives no insight into quality of performance or what to
hand (average 32.2s) 151 target in treatment, which questions its validity for physiothe-
rapy practice
25 26
j. Parkinson Activity Scale (PAS)

m. Physical Activity Scale for the Elderly (PASE)
Activities & Par- 10-item observation performance Good face validity: covers Measurement error for SDDdiff 7.2 points153 Assessment time 30 min; Required materials:
ticipation: functional activities: chair transfer core areas KNGF Guide- total score 2.6, consisting chair, cup, water, bed, bed cover; Current use Activities & 12-question interview: time Unknown Unknown in Unknown in pwp Assessment time: 5 min; No materials or costs; Current use unknown
Capacity measu- (2 items); gait akinesia (2 items); line.115;153 of 1.3 inter-rater error and 10-35% Participation: (hours/week) spent in each in pwp pwp
re of functional bed mobility (6 items).153 Quanti- Concurrent validity: mode- 2.3 patient-induced error.153 Performance activity or participation (yes/ Benefits: easy to administer
mobility (that is tative and qualitative scoring on rate with UPDRS III (motor No significant difference Benefits: supportive for gaining insight into quality measure of phy- no) : weight summed for all
changing body an ordinal scale from 4 (best) to function; r=0.64) and good experts and non-experts, of movement specific for physiotherapy in pwp sical activity activities159 Drawbacks: no psychometric data available for pwp (in elderly, the PASE is a valid &
position and 0 (impossible/help depending) with VAS-Global Functio- with a 1hr training. reliable tool to classify elderly into categories of physical activity159-163)
walking) ning (r=0.79).153 SEM 0.23153 Drawbacks: cannot be used for evaluation; ceiling
effect; ambiguous scoring options
n. Pull Test
k. Parkinson’s Disease Questionnaire (PDQ-39) ICF Scoring Validity Reliability Responsiveness Feasibility 1)
ICF Scoring Validity Reliability Responsiveness Feasibility 1) Body func- Balance performance to external perturba- Concurrent validity to interview based ‘unstable’(≥2 (near) Inter-rater excellent for Unknown in pwp Assessment
tions tion in steady-stance (retropulsion) falls in the previous 6 months or using an (walking) to pre- steady stance positions time 1 min;
Qua- Questionnaire: aspects of func- Grouping of Good test- MCID for ‘a little Assessment time 20 min; Costs: book with instructions must be bought; No materials Movement Unexpected, quick and firm jerk on the vent falling) vs ‘stable’ group: on 1st execution, ‘unstable’ (k 0.98), Nutt (k 0.98) No materials or
lity of life tioning & well-being of pwp.154 items into retest reli- worse’: Mobi- required; Current use 10-35% functions shoulder preferred; 2 steps allowed164, as significant higher than ‘stable’ on all tests, except the and Pastor (k 0.93); costs; Current
(QOL) : 39 questions on mobility (10 subscales ability and lity 0.11; ADL 0.18; Involuntary recommended in the 2004 KNGF Guideline115 steady stance positions; ‘unstable’ higher than ‘controls’ good for SPES (k 0.87) use 10-35%
items); ADL (6 items); emotional not sup- ICC=0.84- overall 0.10156 Benefits: Parkinson’s specific QOL measure; GDG recommends to address items of movement MDS-UPDRS pull test (2007): scoring opti- on 1ste execution, except for Pastor rating164 and Bloem (k 0.85); Benefits: widely
well-being (6 items); stigma (4 ported by 0.89154 relevance in history taking reaction ons: 0, Normal: No problems: Recovers <3 Predictive validity: Nutt: sens 0.63, spec of 0.88, positive Poor for UPDRS (k used, known
items); social support (3 items); analyses155 functions steps; 1, Slight: 3-5 steps, but recovers unai- 0.86, negative 0.69; overall accuracy 0.75; Bloem: sens 0.63)164 amongst
cognition (4 items); communica- Drawbacks: items address limitations correlated to QOL, however, score interpretation is ded; 2. Mild: > 5 steps, but recovers unaided; 0.65, spec 0.85, positive 0.83, negative 0.69; overall ac- Inter-rater excellent for neurologists
tion (3 items); bodily discomfort difficult; construct multi dimensional157; grouping of items into scales complex, meaning 3, Moderate: Stands safely, but absence curacy 0.74; UPDRS: sens 0.66, spec 0.82, pos. 0.83, neg. steady stance positions (communication);
(3 items). 5 point ordinal scale: 0 of scale scores unclear, hampering interpretation.155; responsiveness is questionable; of postural response; falls if not caught; 4, 0.67; overall accuracy 0.71; SPES: sens 0.55, spec 0.92, (k 0.98), Nutt (k 0.93) Drawbacks:
(never) to 4 (always or cannot do floor effects in many pwp; not all items are of importance to, or can be improved by Severe: Very unstable, tends to lose balance pos. 0.88, neg. 0.65; overall accuracy 0.72; Pastor: sens Pastor (k 0.98); good physiothera-
at all). Total: 0-100. physiotherapy; particularly appropriate for use in clinical trials to assess treatments and spontaneously or with just a gentle pull on 0.70, spec 0.69, pos. 0.72, neg. 0.67, overall accuracy for SPES (k 0.87) and pist interest in
interventions (www.dph.ox.ac.uk/research/hsru/PDQ/Intropdq) the shoulders; <3 steps for recovery conside- 0.69; steady stance-positions (right/left): sens 0.45/0.50, Bloem (k 0.85); Poor for backward walk
red normal spec 0.79/0.73, pos. 0.71/0.70, neg. 0.56/0.55; overall ac- UPDRS (k 0.63)164 above external
curacy 0.61/0.61164 pertubation
NOTE: Swedish version: moderate test-retest reliability: ICC=0.76-0.93; adequate internal consistency: Cronbach’s α = 0.72–0.95155
l. PHONE FITT o. Purdue Pegboard Test
Activities & Participa- Interview: type, fre- Unknown in Unknown in Unknown in pwp Assessment time 10 min; No materials or costs; Current use unknown Activities & Participation: Pegs count, Excellent Unknown in pwp Unknown in pwp Assessment time: 10 min; Costs: need to buy the material; Required
tion: quency & intensity of pwp pwp performance measure of carrying, or count of correlations with materials: pegboard test; Current use unknown
Performance measure physical activities158 Benefits: easy to administer moving and handling objects: assembly UPDRS III (r=-0.65) Benefits: easy to administer; Drawbacks: only validity data available
of physical activity visuomotor control, fingertip pinch, items in final and UPDRS total for pwp; gives no insight into quality of performance or what to target
Drawbacks: no psychometric data available for pwp (in elderly (over 65’s) the and release165 task score (r=-0.61)166 in treatment
Phone-FITT was found valid and reliable158)
27 28
p. Survey of Activities and Fear of Falling in the Elderly (SAFFE) r. Unified Parkinson’s Disease Rating Scale (UPDRS)
Activities & Participation: 6-page interview-based question- Unknown in Unknown in pwp Unknown in pwp Assessment time 15 min; No materials or costs; Current use Composite Observation & patient Adequate face validity: Moderate to Excellent test retest SDD: Part III 13 points, Total score Assessment time 30 min (10 min Part I;
Performance measure naire : 22 items assessing feared pwp unknown score for report, ordinal scale 0 constructed by experts reliability: Total ICC=0.92; Menta- 15 points68 15 min part III; 5 min part IV); Required
Changing & maintaining body consequences of falling: fear and disease (normal ) to 4: Satisfactory convergent tion ICC=0.74; ADL ICC=0.85; mo- MDC for Mentation 2 points; materials: paper, chair; Costs required
position avoidance towards specific activi- Benefits: modified Swedish version has good validity & severity Part I Mentation, beha- validity with HY, Schwab tor ICC=0.90173; Total ICC=0.84, Part II 4 points; for Part III 7 points training: $250; Current use 10-35%
ties.167 reliability; Drawbacks: no psychometric data for pwp viour and mood (max 16 & England scales, timed Motor ICC=0.7468 to 13 points68; Total 9 points173 to 15 Benefits: provides insight asymmetry,
points); motor tests172 Poor to moderate inter-rater points68; for Part I 2/16; for Part II dyskineseas, off state predictability (mo-
Part II ADL (max 52); Discriminative validity reliability: Total ICC=0.78, Motor 4/52; Part III 11/108; Total 13/17666 tor part); Drawbacks: mainly assesses
NOTE: Swedish translation of modified version (Yardley), mSAFFE(S): 1-page, self-administered, 17 items assessing avoidance only (scored 1, never, to 3, always).168: mSAFFE(S): Correlations with Part III Motor (max 108); fallers vs non-fallers: UP- ICC=0.6868 MCID: Part III 2.3-2.7 points; Total impairments which cannot be targeted
physical functioning (SF-36) r=-0.76; FES(S) r=-0.74; TUG r=0.67; fast gait speed, r=-0.64; comfortable gait speed, r=-0.52; UPDRS Parts II r=0.52) and III r=0.50; disease duration, r=0.28; and Part IV Complications DRS II, III and total: AUC NOTE: After watching official 4.1 to 4.5 points; MCID motor 4.5- by physiotherapy, is time consuming,
age r=0.08.93; Discriminative validity: higher scores for females vs men and for pwp reporting previous falls, FOF or unsteadiness for than those not reporting this93; Excellent test-retest reliability. (max 23) 0.68, 0.67, 0.70, sens UPDRS Teaching Tape, many 6.7 points ; total 8.5-10.3 points; difficult, costly
ICC=0.92; Adequate internal consistency: α=0.95/0.96, SEM=2.493 0.64, 0.64, 0.7486 differences UPDRS scores trained motor 10.7-10.8 ; total 16.4-17.8175
neurologists on first attempt174
q. Tinetti Performance Oriented Mobility Assessment (POMA) , Gait (G) and Balance (B)

s. WALK-12 Questionnaire
Activities & Partici- POMA-B: Observation Moderate concurrent validity Moderate to good intra-rater Unknown in pwp Assessment time: 15 min (POMA-B 2
pation: balance when performing with gait speed (r=0.53, reliability experienced raters, min); Required materials: armless chair,
capacity measure 9 activities and external POMA-B r=0.52, POMA-G ICC=0.79-0.86169 walking track ≥ 3m, stopwatch; Current
Walking (POMA-G) perturbation (push to r=0.50) and UPDRS motor POMA-G: Excellent intra-rater use >35%
Activities & Participation: 12-item questionnaire: limitations reported when walking Unknown in Unknown in Unknown in pwp Assessment time 5 min; Required materials:
and Changing & sternum; function); (r=0.45)169 reliability mixed group (pwp and Benefits: widely used in elderly;
Performance measure of at home / local community. Original: 5 point ordinal scale pwp pwp pen; Current use: unknown
maintaining body POMA-G: Observation Adequate discriminative validity controls) ICC=0.95171 Drawbacks: floor effects, possibly due to
Walking (1 to 5); max 60 (or transformed to a scale from 0 to 100), Benefits: good validity and reliability Modified
position (POMA-B) gait in 7 activities & body fallers vs non-fallers AUC 0.72 Good inter-rater reliability exclusion of freezing and dual tasks;
higher scores greater limitations Swedish version
Body functions: functions; on a 3-point (sens 0.67; spec 0.59)86 experienced raters ICC=0.84169 combines activities and body function in
involuntary mov. ordinal scale: 0 (unsafe) to POMA-B independent predictor one balance score, difficult to interpreted
reaction functions 2 (safe) (sens 0.71, spec 0.79), OR NOTE: Modified Swedish version: Item 1-3 ordinal 0–2, item 4-12 ordinal 0–4; total score 0 (best) to 42; moderate to strong concurrent validity with measures for physical functioning and gait (FOG,
0.84170; sens 0.76, spec 0.66169 TUG, 10wt, FES) (>0.6)176; Good convergent validity: explains 68% of the variance in scores of a Swedish version FES.177; Excellent test–retest reliability: ICC0.92; SEM 2.6176
NOTE: There are various versions of the POMA, with variations for both the name of the test and means of scoring
29 30
Appendix 17
Evidence-grading tables
to the intervention
recommendations
Appendix provides detailed information on the recommendations developed using the GRADE method, categorised per
intervention:
17.1 Conventional physiotherapy
17.2 Treadmill
17.3 Whole body vibration
17.4 Massage of trigger points
17.5 Cueing
17.6 Strategies for complex motor sequences supported by cueing
17.7 Dance (tango)
17.8 Tai Chi
Recommendations for and against - strong and weak

For each intervention and outcome, recommendations can be for or against and strong or weak (Table 6.2). The classification
reflects the quality of the evidence (high, moderate, low or very low, depending on the influence of study limitations on the
outcome) and the outcome of the meta-analyses, weighted against the burden of the specific intervention. In case of a
recommendation against an intervention for a specific outcome, benefits probably do not outweigh risks and burdens.
Most commonly, effects show a positive trend, but the (wide) confidence interval of the effect includes 0. It does not mean
that the specific intervention has negative effects on that outcome. Risk and burdens are often very low.
Reading information to the tables:

General explanation abbreviations:
• N, number of participants
• CI, confidence interval
• (S)MD, (standardised) mean difference
GRADE levels for strength of evidence: high, moderate, low and very low
CCTs start at the 'high' level. Reasons for downgrading in our selection of CCTs:
a) One level downgrading, because of small sample size, questions on randomisation procedures or (single) blinding,
without influence effects expected (otherwise two levels downgrading would occur)
b) One level downgrading, because of inconsistency results or result of single CCT
31
App. 17.1 Conventional physiotherapy versus no intervention or placebo App. 17.1 Conventional physiotherapy versus no intervention or placebo
Outcome Author & year Intervention targeting: Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks effects Outcome Author & year Intervention targeting: Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks effects
included CCTs Gait (G), Balance (B), Hoehn & Yahr duration, (CI: low to high) evidence recommendation: included CCTs Gait (G), Balance (B), Hoehn & Yahr duration, (CI: low to high) evidence recommendation:
Range of motion (ROM), frequency & time summary burden/benefits Range of motion (ROM), frequency & time summary burden/benefits
Strength (S) Strength (S)
Walking Chandler 1999178 G, B, ROM No intervention Consistent Balance Ashburn 2007194 G, B, S, ROM; at home No intervention N=142, HY2-4 6wks: 7/wk, 60” IRR 0.87 (0.66;1.14) Moderateb Weak against Consistent, non
capacity: Ellis 2005179 G, B, ROM No intervention Median 8 wks MD 0.15 (0.10;0.19) Moderatea Strong for effects, except Capacity1: Goodwin 201131 S, B ; plus 2/wk at home No intervention N=130, HY1-4 10wks: 3/wk, 60” IRR 0.68 (0.43;1.07) significant effect,
speed Fisher 2008180 G, B, ROM, S Education N=378 (range 4-52): 3/ for Schenkman No of also at 10- to 20-
Sage 2009181 G, B; sensory feedback No intervention HY1-3 wk (range 2-7), (addressed only Falls week follow-up
Caglar 2005182 G, B, ROM; home, check No intervention 60” (range 45-90) B, ROM); MD may
Balance Goodwin 201131 S, B ; plus 2/wk at home No intervention N=279, Median 10 wks MD3.83 (1.96;5.69) Moderateb Weak for Inconsistent effects;
Ebersbach 2010183 ROM, B: high amplitude* No intervention* ensure safe street
Capacity: Ashburn 2007194 G, B, S, ROM; at home No intervention HY1-4 (range 6-26): small MD
Schenkman ’98184 B, ROM No intervention crossing
BBS Christofoletti 10193 B, ROM, S; cognition No intervention 3-7/wk, 60”
Reuter 2011185 G (uphill, 50% Nordic W) ROM
best: high
Gait patt.: Fisher 2008180 G, B, ROM, S Education N=38, HY1-2 8-10wks: MD 0.00 (-0.14;0.13) Lowa,b Weak against Inconsistent; 2 very
Balance Ashburn 2007194 G, B, S, ROM; at home No intervention Median 10wks Moderatea Weak for Small MD (without
Stride (m) Hass 2012186 S; progressive No intervention 2-3/wk, 45” small CCTs
Capacity: Schenkman ’98184 B, ROM No intervention N=311 (range 4-17): 3-7/ MD1.82 (0.24;3.39) Schenkman: 2.7);
Walking Caglar 2005182 G, B, ROM; home, check No intervention N=86, HY1-3 Median 8 wks: MD 0.02 (-0.02;0.07) Lowa,b Weak against Inconsistent, small FR Stozek 2003192 G, B, ROM; sensory fb No intervention HY1-4 wk, 45-120” effects inconsistent
capacity Fisher 2008180 G, B, ROM, S Education 3/wk, 50” effects; CI includes best: high Schenkman ’12195 B, ROM Home exercises
Step Sage 2009181 G, B; sensory feedback No intervention 0 Balance Allen 2010189 S, B; mainly at home No intervention Range 8-10wks: MD-2.35 (-5.38;0.69) Moderatea Weak against Consistent effects,
length (m) perform*** Goodwin 201131 S, B ; plus 2/wk at home No intervention N=169, HY1-4 2-3/wk, 30-60” CI includes 0
Walking Fisher 2008180 G, B, ROM, S Education N=56 HY1-3 8-12 wks: MD-0.28 (-5.17;4.62) Lowa,b Weak against Inconsistent effects; FES
capacity: Sage 2009181 G, B; sensory feedback No intervention 3/wk, 45-50” two small CCTs best=low
Cadence ABC Klassen 2007191 S, B, ROM, aerobic No intervention N=38, HY 1-2 Mean 10wks: MD3.63 (-2.09;9.36)190 Moderatea Weak against
Walking Meek 2010187 ROM, S; at gym No intervention Moderatea Weak against Consistent effects, best=high Schilling 201039 S; progressive, high load No intervention 2/wk, 75”
capacity: Schenkman ’98184 B, ROM No intervention N=117 Median 10-12 MD 9.72 CI includes 0; Muscle Allen 2010189 S, B; mainly at home No intervention N=75, HY1-2 Range 8-26 wks: SMD*0.63 (0.13;1.13) Lowa,b Strong for Consistent effects;
distance Schilling 201039 S; progressive, high load No intervention HY1-3 wks: 2-3/wk,60” (-11.55;31.00) best: high intensity functions Schilling 201039 S; progressive, high load No intervention 2-3/wk, 15-50” Allen and Hirsch
(m) Dibble 2006188 S; eccentric, high force G, ROM progressive training Strength: Hirsch 2003196 S2 No intervention2 MD 13.9
Walking Allen 2010189 S, B; mainly at home No intervention N=45, HY? 26 wks: 3/wk, 50” MD-2.40 Lowa,b Weak against Single CCT positive kg
perform: (-5.76;0.96)190 effect, CI includes 0 Strength: Bridgewater ’9725 G, B, ROM, S Social events N=52, HY1-3 12wks: 3/wk,60” MD29.42 Moderatea Strong for Consistent effects;
FOGQ best: low torque Toole 200029 S, B No intervention (25.84;32.99) change 19-30%
Capacity Goodwin 201131 S, B ; & home exercises No intervention Small MD; partly best=high Dibble 2006188 S; eccentric, high force G, ROM
Functional Klassen 2007191 S, B, ROM, aerobic No intervention Median 10 wks MD-1.07 (-1.61;-0.52) Moderateb Weak for inconsistent
mobility: Sage 2009181 G, B; sensory feedback No intervention N=333 (range 4-26): best: low effects31;39; large CI Movement Chandler 1999178 G, B, ROM No intervention Consistent effects;
TUG (s) Schilling39 S; progressive, high load No intervention HY1-4 3-4/wk, 60” functions: Ellis 2005179 G, B, ROM No intervention Moderatea Strong for MD larger than
Stozek 2003192 G, B, ROM; sensory fb No intervention Fisher 2008180 G, B, ROM, S Education N=328 Median 8 wks MD-3.39 (-4.96;-1.82) MCIC (2.7175)
Ebersbach 2010183 ROM, B: high amplitude* No intervention1 UPDRS- Comella 1994197 G, B, ROM No intervention HY1-3 (range 4-52):
Christofoletti10193 B, ROM, S; cognition No intervention motor Sage 2009181 G, B; sensory feedback No intervention 3/wk, 50”
Timed Caglar 2005182 G, B, ROM; home, check No intervention N=76, HY1-3 8-10 wks: MD-1.28 (-2.82;0.26) Moderatea Weak against best: low Ebersbach 2010183 ROM, B: large amplitude No intervention*
Turn (s) Schenkman ’98184 B, ROM No intervention 3-7/wk, 45-60” Schenkman ’12195 B, ROM Home exercises
32 33
App. 17.1 Conventional physiotherapy versus no intervention or placebo App. 17.2 Treadmill versus no treadmill training
Outcome Author & year Intervention targeting: Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks effects Outcome Author & year Intervention details Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks
included CCTs Gait (G), Balance (B), Hoehn & Yahr duration, (CI: low to high) evidence recommendation: included CCTs Hoehn & Yahr duration, (CI: low to high) evidence recommendation: effects
Range of motion (ROM), frequency & time summary burden/benefits frequency & time summary burden/benefits
Strength (S) Capacity Miyai 2000202 BWS 10-20% Conventional PT Consistent
Quality of Allen 2010 189
S, B; mainly at home No intervention Median 12 wks MD-0.13 (-2.80;2.54) Low a,b
Weak against Inconsistent effects; walking: Miyai 2002203 BWS ≤20% Conventional PT N=241 Median 4-6 wks: MD 0.13 (0.05;0.20) Moderatea Strong for effects, except
life: Klassen 2007191 S, B, ROM; aerobic No intervention (range 4-52): largest effect (MD≥- Walking Pohl 2003204 In 50% incremental* 50% PT, 50% HY1-3 3wk, 45” for Kurtais (MD
PDQ-39 Meek 2010187 ROM, S; at gym No intervention 3/wk, 60” 5.6) for prolonged speed Protas 2005205 Varying directions Education -0.03)
(summary) Chandler 1999178 G, B, ROM No intervention N=349 (Allen) or short, high Cakit 2007206 Incremental* Not described
best: low Cruise 2011198 G, S, ROM; aerobic No intervention HY1-4 intensive training Fisher 2008180 High intensity & BWS ≤3% Conventional PT
Dibble 2009199 S; eccentric, high force G, ROM (Dibble) Kurtais 2008207 General treadmill Not described
Ebersbach 2010183 ROM, B: large amplitude No intervention Canning 2012208 At home No intervention
Winward ’12200 ROM, S; at gym No intervention Frazzitta 2009209 Incremental* No intervention
Schenkman ’12195 B, ROM Home exercises Yang 2010210 Downhill, BWS≤40% Conventional PT
EQ-5D** Ashburn 2007194 G, B, S, ROM; at home No intervention N=142, HY2-4 6wks: 7/wk, 60” MD1.10 (-4.29;6.49) Lowa,b Weak against Inconsistent; CI Movement Miyai 2000202 BWS 10-20% Conventional PT Moderatea Strong for Consistent
best: high Goodwin 201131 S, B ; plus 2/wk at home No intervention N=130, HY1-4 10wks: 3/wk, 60” MD-1.40 (-3.63;3.48)31 includes 0; at functions, Miyai 2002203 BWS ≤20% Conventional PT MD 0.06 (0.01;0.12) effects
26wks Ashburn: Gait Pohl 2003204 In 50% incremental* 50% PT, 50% rest N=95, HY1-3 Median 4 wks: 3/
MD7.9(2.5;13.4) patterns: Protas 2005205 Varying directions Education wk, 45”
Stride Fisher 2008180 High intensity & BWS ≤3% Conventional PT
PDQL Yousefi 2009201 S, B, ROM No intervention N=24 10 wks: 4/wk, 60” MD17.7 (1.79;33.61) Lowa,b Weak for Single CCT;
length (m) Yang 2010210 Downhill, BWS≤40% Conventional PT
best: high combined with
EQ-5D & PDQ-39 Capacity Miyai 2000202 BWS 10-20% Conventional PT N=59, HY1-3 Median 6 wks: MD 241.5 (184.8;298.1) Lowa,b Weak for Inconsistent
SMD -0.71 (-3.1; 1.7) walking: Cakit 2007206 Incremental* Not described 3/wk, 35” effects (range
(best: low) Walking Canning 2012208 At home, incremental* No intervention MD: -4.8m to
distance 364m)
Perform. Meek 2010187 ROM, S; at gym No intervention N=39, HY? 12 wks: 1/wk, ?” MD-16.8 (-52.4;18.8) Lowa,b Weak against Sinlge CCT; CI
Activity includes 0 Capacity Miyai 2000202 BWS 10-20% Conventional PT Lowa,b Weak against Inconsistent
levels walking: Miyai 2002203 BWS ≤20% Conventional PT N=108,HY1-3 Median 4 wks: 3/ MD 1.52 (-3.48;6.52) effects; CI
Cadence Protas 2005205 Varying directions Education wk, 45” includes 0 ;
best: low Fisher 2008180 High intensity & BWS ≤3% Conventional PT 4 of 5 CCTs
* Schilling reports kg/kg; **Ashburn used VAS (0-100) only; Goodwin reported adjusted MD, no means – not asked for as pooling will not change conclusion; 1.comparable weekly exercise time in
Yang 2010210 Downhill, BWS≤40% Conventional PT positive MD
HOME and BIG, next to BIG treatment (2.6 vs 2.53hr); 2.both groups also received a 30 min balance training 3/wk; # not adjusted difference; IRR, incidence rate ratio (adjusted for baseline falls)
Capacity Protas 2005205 Incremental* Education N=45, HY1-3 6-8 wks: 3/wk, SMD -0.11 (-0.70;0.47) Lowa,b Weak against Consistent
Functional Kurtais 2008207 General treadmill Not described 45-60” best: low effects but CI
mobility – includes 0;
timed gait** valid tools?
Capacity Cakit 2007206 Incremental* Not described N=31, HY2-3 8 wks: 2/wk, 30” MD 8.29 (1.07;15.51)190 Lowa,b Weak for Single CCT
Balance best: high
BBS
Strength Yang 2010210 Downhill, BWS≤40% Conventional PT N=33, HY1-3 4 wks: 3/wk, 30” MD 18.91 (-10.0;47.9) Lowa,b Weak against Single CCT
(torque, Nm)
34 35
App. 17.2 Treadmill versus no treadmill training

App. 17.4 Massage of trigger points: neuromuscular therapy versus no neuromuscular therapy
Outcome Author & year Intervention details Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks
included CCTs Hoehn & Yahr duration, (CI: low to high) evidence recommendation: effects Outcome Author & year Intervention Control No of pwp; Treatment duration, Overall effects GRADE: GDG: strength Remarks effects
frequency & time summary burden/benefits included CCTs details details mean age* frequency & time (CI: low to high) evidence recommendation:
summary burden/benefits
Movement Fisher 2008180 High intensity & Conventional PT N=38, HY1-2 6-8 wks: 3/wk, MD -0.05 (-5.74;5.64) Lowa,b Weak against Canning MD
functions Canning 2012208 BWS ≤3%, At home, No intervention 35-45” 0; CI includes Walking capacity: Craig 2006214 Trigger point Music N=32, HY1.6 8 wks: 2/wk, 45” no reponse (in text:
UPDRS III incremental* 0; best: high speed massage relaxation no effect)
best: low intensity Movement functions: Craig 2006214 Trigger point Music N=32, HY1.6 8 wks: 2/wk, 45” Data requested;
*incremental walking speed on the treadmill; **Kurtais evaluated climbing up and down a flight of stairs (s), Protas evaluated stepping on and off an 8.8cm step five times (s) UPDRS-motor massage relaxation no reponse (in
best: low text: certain items
positive effects)
Patient-based Craig 2006214 Trigger point Music N=32, HY1.6 8 wks: 2/wk, 45” MD 0.93 (0.47;1.39) Lowa,b Weak for Single, small CCT
treatment effect massage relaxation
App. 17.3 Whole body vibration (WBV) versus no WBV Clinical Global
Outcome Author & year Type of Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks effects Impression (CGI)
included CCTs WBV mean age* duration, (CI: low to high) evidence recommendation: best: high
frequency & time summary burden/benefits Quality of life Craig 2006214 Trigger point Music N=32, HY1.6 8 wks: 2/wk, 45” Data requested; no
PDQ-39 massage relaxation reponse
Capacity Arias 2009211
WBV 6Hz Stand, no vibration N=42; 70.3yr 3-5 wks: MD -0.41 (-1.02;0.21) 213
Low a,b
Strong against Consistent
Functional Ebersbach 2008212 WBV Active balance exercises 2-10/wk, 10-15” effects, CI
mobility: includes 0; safety
TUG considerations
low=best
Balance Arias 2009211 WBV 6Hz Stand, no vibration N=42; 70.3yr 3-5 wks: MD 0.36 (-0.26;0.97)213 Lowa,b Strong against Consistent
Capacity Ebersbach 2008212 WBV Active balance exercises 2-10/wk, 10-15” effects, CI
BBS/Tinetti includes 0; safety
best=high considerations
Balance Arias 2009211 WBV 6Hz Stand, no vibration N=21; 66.7yr 5 wks: MD 16.15 (-45.5;77.8)213 Lowa,b Strong against Single CCT, CI
Capacity 2/wk, 10” includes 0; safety
FR considerations
Movement Arias 2009211 WBV 6Hz Stand, no vibration N=42; 70.3yr 3-5 wks: MD -0.65 (-3.98;2.68)213 Lowa,b Strong against Inconsistent
functions: Ebersbach 2008212 WBV Active balance exercises 2-10/wk, 10-15” effects, CI
UPDRS- includes 0; safety
motor considerations
best=low
36 37
App. 17.5 Cueing versus no cueing App. 17.5 Cueing versus no cueing
Outcome Author & year Cueing: Control details No of Treatment Overall effects GRADE: GDG: strength Remarks effects Outcome Author & year Cueing: Control details No of Treatment Overall effects GRADE: GDG: strength Remarks effects
included CCTs auditory (A) pwp; duration, (CI: low to high) evidence recommendation: included CCTs auditory (A) pwp; duration, (CI: low to high) evidence recommendation:
visual (V) Hoehn & frequency & summary burden/benefits visual (V) Hoehn & frequency & summary burden/benefits
Yahr time Yahr time
Walking De Bruin 2010215 A, self-paced gait No intervention Consistent effects; P&G score Nieuwboer ’07135 A&V, at home, ADL No intervention N=153 3 wks: 3/wk, MD -0.82 (-1.43;-0.21)*** Moderatea Weak for Small change, 5.4%
capacity: Nieuwboer ’07135 A&V, gait, at home No intervention N=240 Median 4 wks: MD 0.07 (0.03;0.11) High Strong for MD expected best: low HY2-4 30”
speed Thaut 1996216 A, gait No intervention HY2-4 3/wk, 30” likely of clinical
QOL**** Nieuwboer ’07135 A&V, gait, at home No intervention N=153 3 wks: 3/wk, MD -1.58 (-5.45;2.29)190 Moderatea Weak against Single CCT; CI
lmeida 2012217 V, gait, 50% treadmill No intervention importance
best: low HY2-4 30” including 0
Gait patt.: De Bruin 2010215 A, self-paced gait No intervention N=48 3 & 13 wks: MD 0.09 (-0.02;0.20)190 Moderatea Weak against Consistent effects;
Stride (m) Thaut 1996216 A, gait No intervention HY2-3 7 & 3/wk, 30” CI just includes 0
*may ensure safe street crossing. Moreover, as in stoke, an increase of 0.03 and 0.13 m/s could translate into a change from a limited household to an unlimited household walker and from unlimited
Walking Nieuwboer ’07135 A&V, gait, at home No intervention N=192 3-6 wks: MD 0.04 (0.02;0.06) High Weak for Very small, household to a most-limited community walker respectively190; **Nieuwboer used FES (MD: 3.74, best=low), Shankar used ABC (MD -3.10, best=high; ***data received upon request; **** PDQ-39; FR,
capacity Almeida 2012217 V, gait, 50% treadmill No intervention HY2-4 3/wk, 30” consistent effect Functional Reach; P&G score includes UPDRS III items for balance and gait13–15 and 29–30
Step (m)
Cadence De Bruin 2010215 A, self-paced gait No intervention N=201 Median 3 wks: MD -2.03 (-5.11;1.05)190 High Weak against Consistent (no)
Nieuwboer ’07135 A&V, gait at home No intervention HY2-4 3/wk, 30” effects, but CI
Thaut 1996216 A, gait No intervention crossing 0
Walking Nieuwboer ’07135 A&V, gait, at home No intervention N=169 3-6 wks: 3/wk, MD -1.01 (-2.17;0.15) High Weak against Consistent effects;
perform: Kadivar 2011218 A, gait: multidirect Self-paced steps HY2-4 30-60” best: low CI includes 0; fin
FOGQ In freezers: freezers-only sign.:
Weak for 5.5% vs 3.6%135;219
Capacity Nieuwboer ’07135 A&V, gait, at home No intervention N=208 6 wks: MD -0.64 (-1.64;0.35) Moderatea Cued gait: Consistent effects,
Functional lmeida 2012217 V, gait, 50% treadmill No intervention HY2-4 3/wk, 30” Weak against but CI includes 0
mobility Kadivar 2011218 A, gait: multidirect Self-paced steps
TUG (s)
Sit-to-stand Mak 2008220 A&V, sit-to-stand No intervention N=33 4 wks: 3/wk, MD -0.73 (-1.14;-0.32) Lowa,b Cued transfer: Positive effects;
(s) HY2-4 20” Weak for single small CCT
Balance Nieuwboer ’07135 A&V, gait, at home No intervention N=153 3 wks: 3/wk, MD 1.46 (-0.32;3.24)* Moderatea Weak against Small, positive
Capacity HY2-4 30” best: high effect, CI includes 0
FR
DGI Kadivar 2011218 A, gait: multidirect Self-paced steps N=16; 6 wks: 3/wk,60” MD 2.80 (0.29;5.31) Lowa,b Weak for Positive effects;
HY2-4 single small CCT
Balance Nieuwboer ’07135 A&V, gait, at home No intervention N=181 3-13wks: SMD 0.11 (-0.11;0.32) Moderatea Weak against Inconsistent; CI
perform** Shankar 2008221 A, comf. gait speed No intervention HY2-4 3/wk, 30” includes 0
Movement De Bruin 2010215 A, self-paced gait No intervention Moderatea Weak for Consistent effects;
functions: Shankar 2008221 A, comfort. gait speed No intervention MD smaller than
UPDRS III Almeida 2012217 V, gait, 50% treadmill No intervention N=166 6 wks: MD -2.27(-4.24;-0.31) MCIC (2.7175)
best: low Marchese 2000222 A&V&T with conv PT Conv PT only HY1.5-4 3/wk, 30”
Mohr 199637 Gait & transfers Role playing
Kadivar 2011218 A, gait: multidirect Self-paced steps
38 39
App. 17.6 Strategies for complex motor sequences supported by cueing App. 17.7 Dance versus no dance (tango)
Outcome Author & year Targeted core Control details No of pwp; Treatment Overall effects GRADE: GDG: strength Remarks effects Outcome Author & year Type of dance Control details No of pwp; Treatment duration, Overall effects# GRADE: GDG: strength Remarks effects
included CCTs areas Hoehn & duration, (CI: low to high) evidence recommendation: included CCTs Hoehn & frequency & time (CI: low; high) evidence recommendation:
Yahr frequency & time summary burden/benefits Yahr summary burden/benefits
Walking Nieuwboer ’01223 Gait & transfers No intervention N=99, HY2-4 2 to 6 wks: MD 0.00 (-0.04;0.05) Moderatea Weak against Inconsistent effects; Walking Hackney 200933 Tango & ballroom No intervention N=67, HY1-3 10 wks: 2/wk, 60” MD 0.01 (-0.09;0.11) Lowa,b Weak against Very small to no effects;
capacity: Morris 2009224 Gait & transfers Conv. PT: S, ROM 8-3/wk, 45-30”* CI including 0 capacity: Hackney 2007228 Tango S, ROM exercises CI including 0; Tango
speed Kamsma 1995225 Transfers No intervention speed only: MD 0.02
Gait Nieuwboer ’01223 Gait & transfers No intervention N=33, HY2-3 6 wks: MD 0.06 (0.02;0.10) Lowa,b Weak for Single CCT; small Gait Hackney 200933 Tango & ballroom No intervention N=48, HY1-3 10 wks: 2/wk, 60” MD 0.07 (-0.10;0.24) Lowa,b Weak against Single, low quality CCT;
patterns: 3/wk, 30” effect patterns: CI including 0; Tango
Stride Stride only: MD 0.10
length length
Step Kamsma 1995225 Transfers No intervention N=38, HY2-4 52 wks : 14 MD -0.02 (-0.08;0.04) Lowa,b Weak against Single CCT; CI Walking Hackney 200933 Tango & ballroom No intervention N=48, HY1-3 10 wks: 2/wk, 60” MD 61.25 (-1.60;124.1) Lowa,b Weak against Single, low quality CCT;
length sessions, 60” including 0 capacity Tango only: MD 66.9
Distance
Walking Nieuwboer ’01223 Gait & transfers No intervention N=33, HY2-3 6 wks: MD -3.81 (-9.03;1.41) Lowa,b Weak against Single CCT; CI
capacity: 3/wk, 30” including 0 Walking Hackney 2007228 Tango S, ROM exercises N=67, HY1-3 10 wks: 2/wk, 60” MD 0.03 (-1.36;1.42) Lowa,b Weak against Inconsistent effects; CI
Cadence perform: Hackney 200933 Tango & ballroom No intervention including 0; Tango only:
FOGQ MD 0.06
Capacity Stack 2011226 Transfers No intervention N=68, HY1-4 4-6 wks: MD 1.02 (0.42;1.63) Moderatea Strong for Small CCTs; best: low
Functional Nieuwboer ’01223 Gait & transfers No intervention 3/wk, 30-60” consistent effects
mobility (PAS chair range 0-8) Capacity Hackney 2007228 Tango S, ROM exercises N=67, HY1-3 10 wks: 2/wk, 60” Dance: Lowa,b Dance: Tango: small MD;
PAS-chair Functional Hackney 200933 Tango & ballroom No intervention MD -1.04 (-2.14;0.05) Weak against consistent positive
best: high mobility: Tango only Tango: effects; low quality
TUG MD 1.23 (-2.30;-0.17) Weak for CCTs
PAS-total Nieuwboer ’01223 Gait & transfers No intervention N=96, HY2-4 6-13 wks: SMD 1.13 (0.74;1.53)*** Moderatea Strong for Small CCTs; low=best
best: high Keus 2007227 No intervention 1-3/wk, 45-60”* consistent, large
Kamsma 1995225 Transfers No intervention effects (22%223);Keus Balance Hackney 2007228 Tango S, ROM exercises N=67, HY1-3 10 wks: 2/wk, 60” MD 2.98 (0.76;5.21) Lowa,b Weak for Small MD; consistent
& Nieuwboer MD3.36 Capacity Hackney 200933 Tango & ballroom No intervention effects; low quality
BBS CCTs; Tango only: MD
Movement Mohr 199637 Gait & transfers Role playing N=41; HY1.5- 10 wks: 2/wk, ??” MD -3.08 (-10.76;4.6) Lowa,b weak against Single CCT; positive best: high 2.84
functions: 4 effect, CI including
UPDRS III 0 ; MD larger than Mini- Duncan 201227 Tango No intervention N=62, HY1-4 12 wks: 2/wk, 60” MD 1.2 (0.68;1.72) Lowa,b Weak for Small MD, increased
(motor) MCIC (2.7175) BESTest** towards 12 months, but
best: high with many drop-outs
UPDRS Morris 2009224 Gait & transfers Conv. PT: S, ROM N=38, HY2-4 2 wks: 8/wk, 45” MD -2.20 (-9.13;4.73) Lowa,b weak against Single CCT; positive
II+III effect, CI including 0 Movement Duncan 201227 Tango No intervention No N=119, HY1-4 10-12 wks*: MD -2.22 (-4.85;0.40) Moderatea Weak against Consistent positive
best: low functions: Hackney 200933 Tango & ballroom intervention 2/wk, 60” effects; CI includes
Patient- Keus 2007227 All No intervention N=27, HY1-4 13 wks: 1/wk, 45” MD 43.78 (9.77;77.79) Lowa,b weak for Single CCT; large CI UPDRS- Hackney 2007228 Tango S, ROM exercises 0; equal results when
based motor* Duncan MD at 12
effect best: low months used (that is
PSI -9); Tango only: MD
-1.97
*Kamsma 52 wks, 14 sessions; **SMD as Kamsma used PAS precursor (% effectively performed activities, MD 52); QOL: Hackney 200933 Tango & ballroom No intervention N=48, HY1-3 10 wks: 2/wk, 60” MD -2.04 (-8.71;4.63) Lowa,b Weak against Single, low quality CCT
PDQ39 with CI including 0;
Tango only: MD -5.51
ROM, range of motion; S, muscle strength; *Duncan 2012 evaluated the ongoing intervention at 52, but to combine the CCTs, data at 12 wks were used27; ** data measured from figure
40 41
App. 17.8 Tai Chi versus no Tai Chi
Outcome Author & year Type of Control details No of pwp; Treatment Overall effects# GRADE: GDG: strength Remarks effects
included CCTs martial artsa Hoehn & Yahr duration, (CI: low; high) evidence recommendation:
frequency & time summary burden/benefits
Walking Hackney 2008 229* Tai Chi Dance N=156; HY1-4 10-24 wks: MD 0.09 (0.03;0.15) Lowa,b Weak for Inconsistent effects
capacity: Li 2012230 Tai Chi Stretching (ROM) 1-2/wk, 60”
speed
Gait Hackney 2008 229* Tai Chi Dance N=156; HY1-4 10-24 wks: MD 0.07 (0.01;0.13) Lowa,b Weak for Inconsistent effects
patterns: Li 2012230 Tai Chi Stretching (ROM) 1-2/wk, 60”
Stride (m)
Walking Hackney 2008229 Tai Chi Dance N=26; HY1-3 10 wks: MD 43.60 (0.71;86.49) Lowa,b Weak for Single, low quality
capacity 2/wk, 60” CCT
Distance
Capacity Hackney 2008229 Li Tai Chi Dance N=156; HY1-4 10-24 wks: MD -0.93 (-1.45;-0.41) High Weak for Small MD;
Functional 2012230 Tai Chi Stretching (ROM) 1-2/wk, 60” consistent positive
mobility: effects
TUG
low=best
Balance Hackney 2008229 Tai Chi Dance N=26; HY1-3 10 wks: 2/wk, 60” MD 3.80 (1.81;5.79) Lowa,b Weak for Single, low quality
Capacity CCT
BBS
Balance Li 2012230 Tai Chi Stretching (ROM) N=130; HY1-4 24 wks: 1/wk, 60” MD 5.0 (2.56;7.44) Moderateb Weak for Small MD; 1 high
Capacity quality CCT
FR
Balance Li 2012230 Tai Chi Stretching (ROM) N=130; HY1-4 24 wks: 1/wk, 60” IRR 0.33 (0.16;0.71) Moderateb Weak for Large difference
Capacity (67% fewer falls) 1
No of falls high quality CCT
Muscle Li 2012230 Tai Chi Stretching (ROM) N=130; HY1-4 24 wks: 1/wk, 60” MD 13.9 (1.51;25.29) Moderateb Weak for Based on 1 high
functions quality CCT
strength:
torque**
Movement Hackney 2008229 Tai Chi Dance N=200; HY1-4 10-24 wks: MD -5.13 (-6.58;-3.67) High Strong for Consistent positive
functions: Schmitz-H 2006231 Qigong No intervention 01-2/wk, 60” effects; MD larger
UPDRS- Li 2012230 Tai Chi Stretching (ROM) than MCIC (2.7175)
motor
low=best
a.searched is for all martial arts, but except for the Schmitz-Hubsch CCT, only Tai Chi is evaluated and therefore used as heading for this table; ROM, range of motion; * sd data of change scores used,
as in Tomlinson Cochrane review190: meters vs centimetres; 1. Schmitz-H 2006231 provided 8 wks 1/wk, an 8 wks break (0/wk), 8 wks 1/wk; **knee extensors; IRR, Incidence-rate ratio
42
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Development and scientific justification

The development of this guideline was initiated and mainly

App. 17.2 Treadmill versus no treadmill training........................................................................................ 35

Available for downloading at www.parkinsonnet.info/euguideline are Reference to this publication

- Development and scientific justification (this document) Copyright © 2014 KNGF/ParkinsonNet

Contents of care Organisation of care Step Aim Search Hits

Contents of care 8 Combine 3 & 5 #3 AND #5 47

Confidence interval MD or SMD ± 1.96*SE

*most frequent reasons for downgrading

Table 1.7 Selection criteria for measurement tools

1.8 Update of this Guideline

CCTs: reasons for exclusion

Appendix 16 Table Appendix 16

Included measurement tools*

Excluded measurement tools

Measurement tools considered 1. 10 Meter Walk (10MW)

*Chapter 5 supports decision-taking towards careful selection of

Note: No single pwp requires the use of all 18 tools.

Appendix 16. Abbreviations and explanation of terminology 1. 10 Meter Walk (10MW)

4. Borg Scale 6-20 7. Five Times Sit-to-Stand (FTSTS)

ICF Scoring Validity Reliability Responsiveness Feasibility 1)

10. History of falling 13. New Freezing of Gait Questionnaire (NFOG-Q)

16. Rapid turns test a. 2-Minute step test

b. Balance Evaluation Systems Test (BESTest)

d. Functional Reach (FR) g. Lindop Scale

h. Movement Disorder Society’s (MDS) revision of the UPDRS (MDS-UPDRS)

j. Parkinson Activity Scale (PAS)

l. PHONE FITT o. Purdue Pegboard Test

ICF Scoring Validity Reliability Responsiveness Feasibility 1)

Recommendations for and against - strong and weak

Reading information to the tables:

App. 17.2 Treadmill versus no treadmill training

App. 17.8 Tai Chi versus no Tai Chi

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