Narrator

Welcome to Talking Physio, an initiative of the Physiotherapy Research Foundation. The foundation supports the profession in a number of ways, including the promotion and translation of research. In this episode of Talking Physio, Mark Elkins, the scientific editor of the Journal of Physiotherapy, interviews Allyson Flynn, a physiotherapy clinical educator at the University of Canberra, about the value of home-based exercise programmes in improving the lives of people with Parkinson's disease. Allyson shares the important findings from her systematic review published in the Journal of Physiotherapy, highlighting the effectiveness of home-based exercise programmes in improving balance related activities, gait speed and the quality of life of people with Parkinson's disease. Just before we start, this episode is proudly sponsored by Flexeze, Australia's number one heat wrap. It's been clinically proven to be effective for back pain relief, lasting up to 15 hours. Flexeze is the exclusive partner of the Physiotherapy Research Foundation. Now let's get into it.

Mark

Before you did your review, what do we already know about the effects of exercise for people with Parkinson's disease?

Allyson

Yeah, so there's lots of research and the research in Parkinson's disease and exercise is really been expanding over the last few years. So we know that exercise can improve mobility, including gait speed, step length, walking capacity. We know it can improve balance, quality of life and in people with mild to moderate Parkinson's disease, we know it can reduce falls. So exercise is a really good thing for people in Parkinson's disease, and we really want to get that message out.

Mark

And what didn't we know about exercise for Parkinson's disease? There was still plenty that we were unsure about right?

Allyson

Yeah like anything, often research asks, you know you answer one question and then you just get 5 more. So I guess now we're really starting to look into the things around, well how much dose do we need? What's the right amount of dose? You don't just give someone a tablet without thinking about how many milligrams you know they're taking. So can we get the dose better? Can we work out how much supervision they need? Can we work out what’s the location? Where's the best place for these people to do it? So more of the specifics about the exercise. What's the best type of exercise to do?

Mark

So that's quite a list. Out of all those things, what made you choose location as the aspect of that exercise prescription that you were going to look at?

Allyson

Yeah, so I guess it sort of started to be a little bit of research and there was sort of this assumption that maybe centre based exercise was superior to home based exercise. So we started to think a bit about location and what is the best location? And we know that people with Parkinson's disease have near normal life expectancy. But Parkinson's disease is progressive, so people are being asked to exercise for decades. In the clinic just the other day, a client said to me, "I've been doing this for 20 years." So we need to be thinking about making it sustainable both from the health resources, but also from the patient's perspective as well. So we thought, maybe if we start with location and work out is there an impact on location? That might be a great place to start.

Mark

So you tackled this by doing a systematic literature review and the method's very strong, so you searched very rigorously. How much evidence did you find with those searchers?

Allyson

Yeah, so in total we came up with 16 trials that were included in the meta analysis. We found 12 trials that compared home based exercise to no active intervention or usual care. And we found 4 trials that compared home based exercise to centre based exercise. So that was really that location comparison that we were looking for.

Mark

So did you find that home based exercise was helpful?

Allyson

Yes, we did. So we found that home based exercise was effective in improving balance related activities and gait speed as well. And it was a clinically significant improvement in gait speed, which was really good to see. And we also saw an improvement in quality of life beyond the intervention period, but not immediately after the intervention. So definitely confident in the results for balance related activities and gait speed. And I think a trend towards an improvement in quality of life.

Mark

And do you think those improvements were, I know it's always very hard to say what's clinically worthwhile and what's not, but do you have a sense for people who are listening about whether you think those effects should be recommended to patients?

Allyson

Yeah, so I think for gait speed, I do feel it's clinically worthwhile. So if we did some back conversions and got it to 0.12 metres per second, which for people who already walk slowly, like in Parkinson's disease, that could be the difference between being able to be a community mobiliser and not, so I think that was a really good sign. Look, the balance related activities, it was a small improvement, but that's consistent with all the studies that look at balance, and balance and mobility and Parkinson's disease. There seems to be this small improvement and given that we know that people with Parkinson's disease fall and balance is not the only component of that, but it is one, if we can help to address some of that, I think that's worthwhile.

Mark

Yeah, it's interesting, we often think that people need to be, we need to be improving people back to the normal value, and yet sometimes a much smaller change can be enough to make a really important difference to the patient, even if it doesn't bring them right back to normal. And we've been seeing that in other sessions at the conference here, where people reported a small change in mls or metres or whatever the measure was, and yet it was enough to make an important clinical difference, so that's a really good interpretation of those results. So then, if we look at the other question that your review answered, which was: is home based exercise as effective as centre based exercise? Because when we started, you said there was a bit of an impression that maybe centre based exercise would be better. And I guess there could be mechanisms for that. So would people have thought that it was more direct supervision, although you can have supervision in home exercise or the group setting? What do you think was people's mindset behind whether why they thought centre based would be better?

Allyson

Yeah so, I think some of it was probably around the concept of supervision and feedback, and we know that people with Parkinson's disease like feedback. So I think people thought well, we can give more feedback if they're in a centre. I think there's probably the other benefits that come with going to a centre, potentially exercising in a group, so those social benefits as well. And we didn't really look at any of that. We really just looked at it from the aspects of balance related activities, gait speed and quality of life. And then maybe some things around compliance and adherence, like maybe people would do it more if they had to come to a centre. So I think that was probably the other factor that that's why people felt that centre based exercise was going to be better.

Mark

And so what did you find? Was home exercise as good or not as good?

Allyson

Yeah, so when the type and dose is equivalent, so you have to make sure you're comparing apples with apples, your home based and centre based exercise was similar and so home is as effective as centre.

Mark

And so that was based on meta analysis of all of those trials and within those meta analyses, did you do any subgroup comparisons and did that, was that informative? Did that tell you anything?

Allyson

Yeah, so we did subgroup analysis for the home based exercise compared to no active intervention. So not looking so much at, I guess, looking at the effectiveness of the home based exercise, and we did the subgroup analysis for dose and supervision. So while our primary idea was to try and answer the question around location, which we did, we also thought it might be nice to gather that extra information and so dose was really not surprising. But we divided the trials, those which we had high dose. So we defined dose in terms of duration and frequency, and we found those that had high dose, which we defined as 150 minutes per week for 6 weeks. So a reasonable amount of exercise. It's about 30 minutes, 5 times a week. And we found those studies that had high dose got an improvement in balance related activities and those with low dose didn't. So, that is a good indicator that we need to make sure we prescribe the right amount. And then, obviously we need to look at ways to make people, encourage people, to maintain and do the exercise.

Mark

So for clinical physiotherapists who are thinking of adopting this model, what methods were used in the studies that you included in your review to keep track of patients and progress the exercise at home? Or maybe not what methods were used in those studies, but what methods would you recommend from what you learnt by doing this study? How should clinical physios keep track of Parkinson's disease patient's home exercise and progression?

Allyson

Yeah, that's a great question, and I probably should just go back one step. So the other subgroup analysis we did was around supervision. So we looked at home based exercise compared to no active intervention for the outcome of balance related activity and again similar to dose, we divided the trial. So those trials that were fully supervised and those, the remaining trials and interestingly, the remaining trials had, on average only 15% supervision. So people were exercising at home with minimal supervision. And when we did that analysis, we also found that studies with minimal supervision had an improvement in balance related activities, whereas the studies that were fully supervised didn't. Now we need to be a little bit careful because there was only two trials that were fully supervised and they were both low dose. So not too concerned about what happened with the fully supervised, but what I really like from that analysis is that minimally supervised exercise was effective, and I think that's probably the take home. So I think it is important that they do keep track. So I think it's really important that the exercise programs are progressed and monitored and then in terms of okay, so how do we do this? So look, really if possible, a home visit. So 9 out of the 12 trials that the home based versus no exercise, had a home visit. So I think, ideally a home visit if you can. At least the opportunity to go through the program with the person before you know they do it at home. So 15 out of the 16 trials had some interaction with the therapist and the client where they went through the exercises, either in their home or in a centre. So the clients need to know what they're going to be doing. And as a therapist, you need to know they're going to be safe. And then people followed up with a whole range of things and I think it probably depends on your resources. But one study used Skype, for example. So, you know, let's get technology going. It's not that hard. Telephone calls. The old adage of you know that reminder that someone's going to call you might mean that you do your exercises that day. Or even just getting people to come back into the centre, you know, occasionally once a month or something like that to keep them going. We have a model in the clinic that I work at. I'm happy to share if you would like?

Mark

Sure.

Allyson

Yes, so we work, at, we're investigating sort of a 5 week on 5 week off model. So where people come in, do their exercise program twice a week for 5 weeks and then get them to exercise at home for 5 weeks. And that's sort of the next step in our research is to look at the effectiveness of that.

Mark

So do you try and coordinate that around on times and off times, with regard to medication or not?

Allyson

Ah look, so first of all, people should exercise on medication. But in the ideal world of running a clinic and fitting that in with everyone's lives and when the clinic times are available, we find times that suit the client and suit the clinic. But generally, like if people experience on and off periods, then we will definitely try and get them into a class so if they're better in the mornings, we'll get them in a morning class. If they're better in the afternoon, we'll put them in an afternoon class. But sometimes it just comes down to practicality. You know, when is it that they can come?

Mark

Sure. So when you did the review, were there any, I mean obviously you found enough data to make some firm clinical recommendations, which is great. That's what clinical physios need. But from a research perspective, were there any frustrations in arising from outcome measures not having any data? Things that you wanted to get data on and when you found all the trials, none of them had measured that?

Allyson

There wasn't anything specific. We've got a really wide range of outcome measures, so we had to come up with this term called Balance Related Activities. And we knew from a research perspective we'd have that problem right from the start. So we did that a priori, and we ranked the outcome measures. So if it included balance and mobility, so something like the mini best, we ranked that at the higher end and then studies that only included balance, like single leg stands we, ranked lower. And if a study reported multiple measures then we took the highest ranked one.

Mark

Yeah, I really like the way you did that ranking of the balance test. I'd never seen that before in a paper and when I looked at it, I went, "Oh is that alright? Is that kosher?" And the more I thought about, I thought this is a really clever way of dealing with that problem of a whole mess of outcome measures and multiple ones for balance in the one trial and which one are you going to pick. So I really liked that aspect of your paper. I guess with my question, what I was more thinking about was, if there were some outcomes, even if they weren't included in your review, that maybe we should be thinking about in future research in Parkinson's disease? So things like, what did it do to their socialisation or their social aspects of their quality of life or their aerobic fitness? Or, you know, are there things a bit more peripheral to the usual balance mobility that we may be overlooking? Or as we get better treatments, we can think, well maybe we can't just, we won't just improve balance and safe mobilisation, but we might improve something broader?

Allyson

Yes, so I think there's two things there like, what do the patients want? Do they want to exercise in a group or at a centre? So we didn't really look at any of what's the patient's motivation or the patient satisfaction or any of those types of things. So it's all good and well to say, well the evidence is you should exercise at home, but if you don't want to exercise at home, then you're probably not going to do it. So I think probably more from the patient perspective. And that might be in the qualitative literature and we didn't really go looking for that, I guess.

Mark

So if you were to wrap up the key sort of take home messages for clinicians from your paper, how would you sum that up?

Allyson

Yeah, so I think I've got it down to 4 points. So I talk about the fact that location doesn't matter. So do the exercise with considering the preference of the person with Parkinson's and what your resources are. Second of all, we need the right exercise. So in all the trials, exercise was prescribed by a physiotherapist, so these people didn't download an app and just start exercising. They had the right exercise. You need to consider the dose, but not just the amount of exercise, so thinking about that 150 minutes a week, but also consider how you're going to make this ongoing. Remember, people need to exercise over decades. And then finally, the exercise needs to be monitored and progressed, but not necessarily fully supervised. So consider what are some other options for doing this? You know, can we use Telehealth? Are there other ways that we can do this?

Mark

Okay, great. Thanks very much for chatting with us today.

Allyson

Thanks a lot, Mark.

Narrator

That was Mark Elkins and Allyson Flynn and you have been listening to another episode of Talking Physio brought to you by Flexeze and the Physiotherapy Research Program. I hope it's been both informative and interesting. I look forward to bringing you another episode very soon. Thanks for listening.