Before you did your review, what was already known about the effects of exercise for people with Parkinson’s disease?

Exercise is an integral part of the management of Parkinson’s disease. There is increasing high-quality evidence that exercise can improve mobility (standing up, walking speed, step length and walking capacity), balance, muscle strength and quality of life. In people with mild-to-moderate Parkinson’s disease, exercise has also been shown to reduce falls.

And what wasn’t known about exercise for Parkinson’s disease?

Like any area of growing research there are often more questions than answers. People are still investigating what is the optimal location (home versus centre-based), ideal dose (both duration and frequency), type, mode of delivery (individual or group), and amount of supervision.

That’s quite a list. What made you choose the location?

There was a suggestion in the literature that home-based exercise was not as effective as centre-based exercise. We were particularly interested in location because we want exercise to be accessible and sustainable for people with Parkinson’s disease. Life expectancy for people with Parkinson’s disease is nearly normal, but the disease is progressive so people need to maintain exercise over decades.

Home exercise can be sustained over a prolonged period with minimal resources. Given that the cost of fully supervised centre- based exercise is unlikely to be sustainable in the context of a neurodegenerative condition, it was crucial to identify whether home-based prescribed exercise was effective.

How much evidence did you find?

We were principally interested in exercise that was prescribed by a qualified health professional (physiotherapist or exercise physiologist), involved standing or walking, and had a minimum dose of at least four sessions over two weeks. To be considered a home-based program, a minimum of two-thirds of the exercise program had to be conducted at home. There were 12 studies comparing home-based exercise to usual care and four studies which compared home-based exercise to equivalent centre-based exercise. The majority of the people in the studies had mild-to- moderate Parkinson’s disease.

Was home-based exercise helpful?

Yes, when compared with usual care home-based exercise resulted in a small improvement in balance-related activities (SMD 0.21 95% CI 0.10 to 0.32) and a clinically significant increase in gait speed (SMD 0.30, 95% CI 0.12 to 0.49) immediately after the intervention. When investigating quality of life there was no improvement immediately after the intervention (SMD 0.11 95% CI -0.01 to 0.23), but quality of life did improve slightly during the follow-up period (SMD 0.23 95% CI 0.06 to 0.39), which ranged from six to 46 weeks.

Your review also looked at whether home-based exercise is as effective as centre-based exercise. What did you discover by pooling the available comparisons of those two locations?

When comparing home-based and centre-based exercise which, importantly, was of equivalent type and dose, the benefits in balance- related actives and quality of life were similar irrespective of the location.

You also did some subgroup analyses. Were they informative?

Yes, we also investigated the impact of dose and supervision on balance-related activities when comparing home-based exercise to usual care. We found that high dose home-based exercise (≥150 minutes per week for six weeks) was effective in improving balance- related activities immediately after the intervention, while low dose exercise (150 minutes per week for six weeks) was not. This finding confirms the need to ensure that home-based exercise is delivered at an appropriate dose.

We also found that low levels of supervision (less than 33 per cent of exercise sessions) were effective in improving balance related activities immediately after the intervention, while fully supervised home-based exercise (100 per cent supervision of exercise sessions) was not. The interventions that provided 100 per cent supervision were only able to provide low dose exercise, which supports our thinking that fully supervised home-based exercise is resource intensive and unlikely to be sustainable.

For physiotherapists thinking of adopting this model, what methods were used in the studies to keep track of patients and progress the exercise?

Monitoring and progressing home-based exercise was crucial because in some studies people exercised for six months. There was a wide range of methods used to monitor and progress the exercises. In 15 out of the 16 studies included in the systematic review there was at least one supervised session either at home or at a centre. Most studies also included some form of ongoing review and contact with the participants, such as phone calls, occasional group-based sessions at a centre, additional home-visits, and Skype. Two studies also asked the caregiver to be present when the participant was exercising, to ensure safety. Based on the current evidence, for people with mild-to-moderate Parkinson’s disease, we recommend at least one home visit be conducted to ensure safe and effective exercise is possible in the home environment, with ongoing monitoring (this can be done remotely) and/or follow-up visits to promote adherence and facilitate progression.

Click here to read this systematic review published in the Journal of Physiotherapy.

Allyson Flynn, APAM, is a PhD candidate at the University of Sydney, investigating physiotherapy service delivery in people with Parkinson’s disease. Allyson also works as a physiotherapy clinical educator at the University of Canberra, where she is responsible for the student-led neurological rehabilitation clinic.