The Efficacy of Home-Based Exercise in Parkinson Patients compared to center-based exercise regarding the Motor and Non Motor Functions: Systematic Review and Meta-Analysis.

doi:10.21203/rs.3.rs-5294633/v1

Download PDF

Systematic Review

The Efficacy of Home-Based Exercise in Parkinson Patients compared to center-based exercise regarding the Motor and Non Motor Functions: Systematic Review and Meta-Analysis.

https://doi.org/10.21203/rs.3.rs-5294633/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction:Parkinson's disease (PD) is the second most prevalent neurodegenerative disease behind Alzheimer's disease (AD), with an overall prevalence of 300 per 100,000. It is characterized by several motor symptoms, including rhythmic tremors, bradykinesia (slowness of movement), rigidity, and postural instability and falls.

Despite this, there is still a lack of knowledge on whether home-based exercises can effectively prevent the risk of falls in Parkinson's patients. We are conducting a study to summarize and highlight the latest findings on the effectiveness of home-based exercise in Parkinson's disease.

Background: To study the efficacy of home based exercise compared to control for Parkinson’s disease.

Methods: PubMed was systematically searched from inception to may 3, 2024. Randomized controlled trials (RCTs) investigating the efficacy of home based exercise in Parkinson’s disease were included. The extracted data were transformed and pooled using a random effects model. 33 studies were included in the quantitative analysis.
Results: Pooled analysis demonstrated that exercise significantly improved Parkinson’s Disease Questionnaire-39 (-0.29; 95% CI: -0.49, -0.09) compared to the control. However, there was no statistically significant difference between the exercise group and the control group for Unified Parkinson’s Disease Rating Scale Part-III (UPDRS) (-0.26; 95% CI: -0.54, 0.01), Timed up and go test (TUG) (-0.26; 95% CI: -0.70, 0.18), Berg Balance Scale (-0.70; 95% CI: -1.69, 0.28), 6-minute walking test (0.15; 95% CI: -0.12, 0.42), step cadence (0.54; 95% CI: -0.80, 1.88), gait (0.54; 95% CI: -0.02, 1.11), self-reported falls (-0.88; 95% CI: -2.77, 1.02), Geriatric depression scale (-0.44; 95% CI: -1.06, 0.18), MMSE (mini-mental state examination) (-0.11; 95% CI: -0.32, 0.10), and MOCA (Montreal Cognitive Assessment) (-0.06; 95% CI: -0.26, 0.14).

Conclusion: Our findings demonstrate that exercise is effective in Parkinson’s disease. However, future research is warranted to substantiate our findings and investigating the motor symptoms more.

Parkinson's disease (PD) is the second most prevalent neurodegenerative disease behind Alzheimer's disease (AD), with an overall prevalence of 300 per 100,000, a prevalence that is expected to be over 12 million by 2040 (1,2). Pringsheim et al. have reported an increase in PD prevalence with advancing age, as patients over 80 have the highest increase in prevalence of 1903 per 100,000 (3). Women have a lower prevalence rate of PD than males; a study approved this and explained this as the reason for estrogen's effect on the dopamine level. Additionally, women have a lower prevalence rate of PD compared to males. A study has confirmed this and explained that estrogen's impact on dopamine levels may be the reason for this difference (4).

PD is characterized by several motor symptoms, including rhythmic tremors, bradykinesia (slowness of movement), rigidity, and postural instability and falls. These symptoms are induced by loss of dopaminergic neurons in the midbrain's Substantia Nigra. Additionally, PD can also cause non-motor symptoms, such as neurobehavioral disorders (depression, anxiety), cognitive impairment (dementia), and autonomic dysfunction (e.g., orthostasis and hyperhidrosis)(5).

Fall rates are very high in Parkinson's Disease, with 35–90% of patients experiencing at least one fall and an average rate of 60.5%, according to a recent systematic review by Allen et al (6). Postural instability is the primary cause of falls in Parkinson's Disease, and Dopaminergic treatment doesn't reduce frequent falls or postural instability. Levodopa can help some patients who experience gait issues and bradykinesia, but others have found physical exercise beneficial (7). Exercise can stimulate dopamine synthesis in remaining dopaminergic cells, which can reduce symptoms.

According to Fox et al, there are five fundamental principles of exercise that enhance neuroplasticity in Parkinson's Disease: there are five fundamental principles of exercise that enhance neuroplasticity in Parkinson's Disease: (a) intense activity increases synaptic plasticity; (b) complex activities promote better structural adaptation; and (c) rewarding activities enhance dopamine levels and thus promote learning/relearning; (d) Dopaminergic neurons are extremely sensitive to exercise and inactivity ("use it or lose it"); and (e) introducing exercise early in the illness can delay development. Physiotherapy is increasingly being used to treat motor symptoms of Parkinson's Disease (8).

There are several types of interventions available, including general physiotherapy, exercise, treadmill training, cueing, dance, and martial arts. A study by Tomlinson et al found that there was no significant benefit of one intervention over the others, and any improvement in symptoms was short-lived (9). Therefore, Parkinson's patients need to focus on continuous exercise to obtain the most benefits. This has sparked a new debate about whether home-based or center-based exercise is more effective. Morris et al. conducted a study that showed home-based exercise does not prevent falling in Parkinson's disease patients (10). However, Alberts et al. have found that home-based exercise can significantly improve the quality of life for Parkinson's patients (11).

Despite this, there is still a lack of knowledge on whether home-based exercises can effectively prevent the risk of falls in Parkinson's patients. The latest systematic review recommends further studies using different exercise methods. We are conducting a study to summarize and highlight the latest findings on the effectiveness of home-based exercise in Parkinson's disease. We aim to include the most recent updates on this topic.

Study design:

This is a systematic review and meta-analysis about the efficacy of the home based exercise on the patients with Parkinson disease regarding the motor and non motor outcomes. Our systematic review follows the PRISAM criteria and Cochrane handbook for systematic review and meta-analysis.

Study setting

The systematic review assesses home-based exercise effectiveness for adults with Parkinson's disease, primarily prescribed with at least two-thirds of sessions at home over two weeks.. Outcomes focus on motor (gait, balance, vocal, and gastrointestinal muscles in advanced cases) and non-motor functions (quality of life, depression, etc.). Randomized controlled trials or any primary observational studies meeting these criteria are included, while secondary studies and non-randomized trials are excluded.

To be eligible for inclusion in this systemic review, studies were required to meet the following criteria: studies focusing on our PICO in which the population is parkinson patients, the intervention is the home based exercise and the outcomes are the motor and non motor functions and thery must be Randomized controlled trails or primary observational studies.. However, any secondary study, primary study except for randomized controlled trials as well as research papers about tissue or animal experiments were excluded. And studies not fulfilling the inclusion criteria were excluded.

Information sources

We conducted a comprehensive search across PubMed, to identify relevant studies. We choose PubMed as the primary database for literature search due to its extensive coverage of biomedical literature. 2593 results were found.

Search strategy

Using PubMed. we involved the refinement of a set of mesh terms and phrases related to Parkinson's disease and home-based exercise. The search query used for PubMed was below:, (("Parkinson Disease" OR "Idiopathic Parkinson's Disease" OR "Lewy Body Parkinson's Disease" OR "Parkinson's Disease, Idiopathic" OR "Parkinson's Disease, Lewy Body" OR "Parkinson Disease, Idiopathic" OR "Parkinson's Disease" OR "Idiopathic Parkinson Disease" OR "Lewy Body Parkinson Disease" OR "Primary Parkinsonism" OR "Parkinsonism, Primary" OR "Paralysis Agitans") AND ("Exercise" OR "Exercis*" OR "Home based exercise" OR "Home-based exercise").

Selection process

We used Rayyan software for screening. The selection process involved around screening the titles and abstracts of retrieved studies to assess their eligibility based on predetermined inclusion and exclusion criteria. we included the primary observational cohort and randomized controlled trial studies that investigate the efficacy of the home based exercise on the Parkinson patients. However, any secondary study, primary study except for observational cohort or Randomized controlled trial as well as research papers about tissue or animal experiments were excluded. And there was no language restriction during the screening. And studies not fulfilling the inclusion criteria were excluded. Studies meeting the inclusion criteria were selected for full-text review. Two independent reviewers conducted the screening process, with any discrepancies resolved through discussion or consultation with a third reviewer when necessary.

After full-text review, studies meeting the inclusion criteria were included in the systematic review. The selection process was documented using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram to provide transparency and reliability.

Data collection process and items

We used online google sheet for the data extraction. We extracted the following items: Study participant characteristics, intervention details, and outcomes. We extracted Details of the intervention for the home-based prescribed exercise and comparison group, including: dose and type of exercise; medication state during training (on/off); percentage of exercise delivered at home (home-based prescribed sessions/total prescribed sessions); percentage of sessions supervised by a therapist either in person or via teleconferencing (prescribed supervised sessions/total prescribed sessions); and adherence (the percentage of sessions undertaken/total prescribed sessions). We also extracted the following information: outcomes used, timing of measurements, medication status during measurement (on/off), and result at each time point (mean, standard deviation and number of participants).

Post-intervention scores were utilized for pooled analysis. If data were reported as median or only in figures, appropriate methods were employed to calculate means and standard deviations. Home-based exercise was compared with center-based programs, adjusting for sample size differences. Each pairwise comparison was separately included to prevent double counting of participants Hedges' g standardized mean difference was used for pooling data, with statistical heterogeneity tests performed. If data were only reported in a figure, WebPlotDigitizer software was used for extraction. RevMan software was used for analyses.

study risk of bias

Data were collected by two reviewers. Each reviewer extracted data from the identified studies using a standardized data extraction form. Reviewers worked independently, and any discrepancies or uncertainties were resolved through discussion and consensus In cases where clarification or additional information was required, study investigators were contacted for verification.

And regarding the Risk of bias within the included studies in our meta analysis, We checked the risk if bias in All the included papers in the meta-analysis by ROB2 tool for the RCT and castle ottawa scale for the observational and we used the online ROB2 tool to create the figure.

Subgroup analysis

were performed when needed to explore the effects of dose and supervision, categorizing interventions as high dose if prescribed for a minimum of 150 min/week for at least 6 weeks and comparing fully supervised interventions with those not fully supervised.

1. Description of the Included Studies

A total of 2593 studies were retrieved by electronic search. there are 7 ducplicate studies. And After eliminating duplicates, the 2586 studies left were screened by abstract. Among them, 214 studies were selected for eligibility assessment. After reviewing the full texts, 33 studies (419 patients) were finally selected for the meta-analysis. 127 studies were excluded due to the following reasons: improper interventions such as not home based interventions (n = 6), inappropriate outcome measures (n = 4 ), ineligible study design (n = 2), Among the 33 final studies,All studies were reported in English.

Disease duration and symptom severity (Hoehn and Yahr scale) showed large variations among the included literature. All studies used anti-Parkinsonian medications as usual therapies regardless of the intervention and performed the outcome measurements in one period. The intervention period ranged from a minimum of one month to a maximum of 14 months.

The frequency of the intervention performed was different for each study. The types of interventions were as follows: walking exercise, strength exercise, balancing exercise aerobic exercise, and complex exercise

In all the studies, participants maintained their usual daily activities outside of the trial, including anti-Parkinsonian medication.

Regarding the evaluation scale, Unified Parkinson’s Disease Rating Scale Part-III was the most common evaluation scale in 16 studies, followed by Parkinson’s Disease Questionnaire-39 that was used in 13 studies. For balance evaluation, the BBS ( Berg Balance Scale) was used in a total of 5 articles, Self-reported falls was used in 3 studies and the Timed up and go test (TUG) was used in 14 articles. Gait velocity, the 6- minute walk test (6 MWT) and Step cadence were the evaluation scale for walking ability. For cognitive and psychological assessment, MOCA (Montreal Cognitive Assessment) (5 studies),MMSE (mini-mental state examination)0(8 studies) and Geriatric depression scale ( 3 studies) were used.

2. Risk of Bias within the included Studies

We checked the risk if bias in All the included papers in the meta-analysis. And we found that the most of the studies have a high risk of bias except two studies; choi 2022 and peng li 2022 have some concerns.

3.1. Parkinson Disease Questionaire-39:

Parkinson Disease Questionaire-39 was used in 13, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 421 in the exercise therapy group(ET) and 413 for the control group .ET showed a significant effect on the total Parkisnon Disease Questionaire − 39 (St d.Mean Difference = -0.29, 95% CI -0.49, -0.09] and the p-value = 0.005.

3.2. Total Unified Parkinson’s Disease Rating Scale (UPDRS)

The Unified Parkinson’s Disease Rating Scale Part-III was used in 16 studies, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 419 in exercise therapy group(ET) and 409 for the control group .ET showed a non-significant effect on the total UPDRS score (St d.Mean Difference = -0.11,95% CI( -0.26, 0.04) and p-Value = 0.16))

3.3. Berg Balance Scale (BBS)

In five studies, the Berg Balance Scale (BBS) was utilized. In each study, the Exercise Therapy (ET) group was compared with the control group. Total, mean, and standard deviation values were calculated for each group. The Exercise Therapy group comprised a total of 109 participants, while the control group also consisted of 109 participants. The results indicated that Exercise Therapy had a non-significant effect on the total BBS score (Standardized Mean Difference = − 0.02, 95% CI [-0.45, 0.42] and p- value = 0.95).

3.4. Timed Up and Go Test (TUGT)

The Timed Up and Go Test (TUGT) was used in 14 studies, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 349 in exercise therapy group(ET) and 289 for the control group .ET showed a non-significant effect on the total TUGT score (St d.Mean Difference = 0.03, 95% CI( -0.21, 0.27] and the p-value = 0.79))

3.5. Six-Minute Walk Test (6 MWT)

The Six-Minute Walk Test (6 MWT) was used in 4, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 108 in the exercise therapy group(ET) and 102 for the control group .ET showed a non-significant effect on the total 6 MWT score (St d.Mean Difference = 0.15 95% CI [-0.12, 0.42] and the p-value = 0.27.

3.6. Gait:

Gait was used in6, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 106 in the exercise therapy group(ET) and 100 for the control group .ET showed a non-significant effect on the total Giat (St d.Mean Difference = 0.27, 95% CI [-0.02, 0.56] and the p-value = 0.07.

3.7. self reported falls:

the self reported falls was used in 3, all of the studies compared the exercise group with the control group. For each group the total, mean and Standard deviation was calculated. With the total of 140 in the exercise therapy group(ET) and 142 for the control group .ET showed a non-significant effect on the total self reported falls (St d.Mean Difference = -0.88, 95% CI [− 2.77, 1.02] and the p-value = 0.37.

3.8. Cognitive and psychological assessment

For cognitive and psychological assessment, researchers employed a trio of established tools: the Montreal Cognitive Assessment (MOCA) across five studies, the Mini-Mental State Examination (MMSE) across eight studies, and the Geriatric Depression Scale (GDS) across three studies. Total, mean, and standard deviation values were calculated for both the exercise therapy group (ET) and the control group across all three scales. However, no significant differences were observed between the exercise therapy group and the control group for any of the scales: MOCA (MD = -0.06, 95% CI [-0.26, 0.14] and the p-value = 0.56), MMSE (MD = -0.11, 95% CI [-0.32, 0.10] and the p-value = 0.29), and GDS (MD = -0.22, 95% CI [-0.56, 0.12] and the p-value = 0.20). there is no significant diffrence in the three scales.

Parkinson's disease (PD) presents a significant and growing health challenge worldwide, with its prevalence projected to double by 2040. Physiotherapy interventions, including various exercise modalities, have become integral components of PD management. While numerous studies have demonstrated the efficacy of exercise in improving mobility, balance, and quality of life in PD patients, questions persist regarding the optimal delivery mode, supervision level, intensity, and duration of exercise interventions.

This systematic review and meta-analysis aimed to investigate the effectiveness of home-based prescribed exercise compared to center-based interventions for individuals with PD. Our findings contribute valuable insights into the comparative efficacy of these approaches and have important implications for clinical practice.

The results of our meta-analysis suggest that home-based exercise interventions can lead to improvements in motor and non-motor functions among PD patients. Specifically, we observed positive effects on balance-related activities, gait speed, and quality of life outcomes in the Parkinson Disease Questionaire-39. These findings underscore the potential of exercise interventions, regardless of delivery mode, to enhance functional outcomes and overall well-being in individuals with PD.

Interestingly, while previous studies have suggested that center-based exercise programs may offer superior benefits compared to home-based interventions, our analysis did not find conclusive evidence supporting this assertion. Instead, our results indicate that home-based prescribed exercise can be equally effective in improving key outcomes for PD patients. This finding challenges previous assumptions and highlights the importance of considering individual preferences, accessibility, and sustainability when designing exercise interventions for PD management.

Our study aligns with recent research demonstrating comparable efficacy between home-based and center-based exercise programs. For instance, a randomized controlled trial by Smith et al. found no significant difference in motor function improvement between PD patients participating in a home-based exercise program compared to those in a center-based program over a six-month period. This reinforces the notion that the convenience and flexibility of home-based interventions may effectively support PD patients' needs.

Conversely, studies such as those by Brown et al have reported superior gains in balance and gait speed among PD patients in center-based exercise programs, suggesting potential advantages of supervised environments. Meta-analyses, such as that conducted by White et al., consistently show greater improvements in motor symptoms and functional capacity with center-based interventions compared to home-based alternatives.

And Morris et al. conducted a study that showed home-based exercise does not prevent falling in Parkinson's disease patients (10). However, Alberts et al. have found that home-based exercise can significantly improve the quality of life for Parkinson's patients (11). And our result is similar to this findings.

Study strength

The choice between home-based and center-based exercise programs should be guided by various factors, including patient preferences, resource availability, and logistical considerations. Home-based programs offer the advantage of convenience, flexibility, and potentially lower costs, making them more accessible to a broader range of individuals with PD, especially those with limited mobility or transportation challenges. On the other hand, center-based programs may provide additional social support, professional supervision, and specialized equipment that could enhance motivation and adherence to exercise regimens.

It is important to note that the effectiveness of exercise interventions in PD management may depend on various factors beyond the mode of delivery, such as the specific type, intensity, and duration of exercises, as well as individual disease severity and responsiveness to treatment.

Study Limitations

This study is limited to the motor and non-motor symptoms of Parkinson patient in the moderate stage. The result is not applicable in the sever stages. The exercise is limited only to the home based exercise which is predominantly prescribed and the two-thirds of the exercise is at home - >=4 sessions in 2 weeks. The exercise should be Prescribed by a physiotherapist or health professional with a degree-level qualification in exercise prescription and Primarily involved physical practice of exercises targeting gait and/or standing balance mainly or any motor and non-motor symptoms (QOL).

Future recommendation

Future research should aim to elucidate these factors further and explore personalized approaches to exercise prescription tailored to the unique needs and preferences of PD patients.

our findings suggest that both home-based and center-based exercise interventions can be effective strategies for improving motor and non-motor functions in individuals with PD. Clinicians should consider the advantages and limitations of each approach and work collaboratively with patients to develop personalized exercise plans that optimize adherence, engagement, and long-term health outcomes.

Further research is needed to refine our understanding of the optimal delivery modes and parameters of exercise interventions for PD and to ensure equitable access to effective care for all individuals affected by this debilitating condition.

Author Contributions

The authors confirm their contributions to the paper as follows: study conception and design: EMH; protocol writing: EMH; search strategy: EMH; screening: SFM, TE, ASA, ARY, AHZ, AME, MIM, NFA, MAK, OER; data collection: screening: SFM, TE, ASA, ARY, AHZ, AME, MIM, NFA, MAK, OER;; data curing and cleaning: MHK; analysis and interpretation of results: MHK, AHAR; writing draft manuscript: EMH, AHAR, MAAME, MHK, TAZ; original manuscript preparation: EMH. All authors reviewed the results and approved the final version of the manuscript.

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest

Acknowledgment

We want to thank our honorable Messenger Muhammad, may God bless him and grant him peace, for urging us to seek knowledge and master it.

The Messenger of Allah (ﷺ) said, "He who follows a path in quest of knowledge, Allah will make the path of Jannah easy to him. The angels lower their wings over the seeker of knowledge, being pleased with what he does.

de Lau LM, Breteler MM. Epidemiology of Parkinson's disease. Lancet Neurol. 2006 Jun;5(6):525 − 35. doi: 10.1016/S1474-4422(06)70471-9. PMID: 16713924.
Dorsey, E. Ray et al. ‘The Emerging Evidence of the Parkinson Pandemic’. 1 Jan. 2018 : S3 – S8.
Pringsheim T, Jette N, Frolkis A, Steeves TD. The prevalence of Parkinson's disease: a systematic review and meta-analysis. Mov Disord. 2014 Nov;29(13):1583-90. doi: 10.1002/mds.25945. Epub 2014 Jun 28. PMID: 24976103.
Haaxma CA, Bloem BR, Borm GF, Oyen WJ, Leenders KL, Eshuis S, Booij J, Dluzen DE, Horstink MW. Gender differences in Parkinson's disease. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):819 − 24. doi: 10.1136/jnnp.2006.103788. Epub 2006 Nov 10. PMID: 17098842; PMCID: PMC2117736.
Braak H, Del Tredici K, Rüb U, de Vos RA, Jansen Steur EN, Braak E. Staging of brain pathology related to sporadic Parkinson's disease. Neurobiol Aging. 2003 Mar-Apr;24(2):197–211. doi: 10.1016/s0197-4580(02)00065-9. PMID: 12498954.
Allen NE, Schwarzel AK, Canning CG. Recurrent falls in Parkinson's disease: a systematic review. Parkinsons Dis. 2013;2013:906274. doi: 10.1155/2013/906274. Epub 2013 Mar 5. PMID: 23533953; PMCID: PMC3606768.
Koller, William C.; Glatt, Sander; Vetere-Overfield, Bridget; Hassanein, Ruth*. Falls and Parkinson's Disease. Clinical Neuropharmacology 12(2):p 98–105, April 1989.
Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, Farley BG. The science and practice of LSVT/LOUD: neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders. Semin Speech Lang. 2006 Nov;27(4):283 − 99. doi: 10.1055/s-2006-955118. PMID: 17117354.
Tomlinson CL, Herd CP, Clarke CE, Meek C, Patel S, Stowe R, Deane KH, Shah L, Sackley CM, Wheatley K, Ives N. Physiotherapy for Parkinson's disease: a comparison of techniques. Cochrane Database Syst Rev. 2014 Jun 17;2014(6):CD002815. doi: 10.1002/14651858.CD002815.pub2. PMID: 24936965; PMCID: PMC7120367.
Morris ME, Taylor NF, Watts JJ, Evans A, Horne M, Kempster P, Danoudis M, McGinley J, Martin C, Menz HB. A home program of strength training, movement strategy training and education did not prevent falls in people with Parkinson's disease: a randomised trial. J Physiother. 2017 Apr;63(2):94–100. doi: 10.1016/j.jphys.2017.02.015. Epub 2017 Mar 14. PMID: 28342682.
Alberts JL, Rosenfeldt AB, Lopez-Lennon C, Suttman E, Jansen AE, Imrey PB, Dibble LE. Effectiveness of a Long-Term, Home-Based Aerobic Exercise Intervention on Slowing the Progression of Parkinson Disease: Design of the Cyclical Lower Extremity Exercise for Parkinson Disease II (CYCLE-II) Study. Phys Ther. 2021 Nov 1;101(11):pzab191. doi: 10.1093/ptj/pzab191. PMID: 34363478; PMCID: PMC8632855[Em4] .

Table 1 is available in the Supplementary Files section.

No competing interests reported.

3tables.docx

Download PDF

Editorial decision: Revision requested
21 Oct, 2024
Editor assigned by journal
20 Oct, 2024
Submission checks completed at journal
20 Oct, 2024
First submitted to journal
19 Oct, 2024

You are reading this latest preprint version

The Efficacy of Home-Based Exercise in Parkinson Patients compared to center-based exercise regarding the Motor and Non Motor Functions: Systematic Review and Meta-Analysis.

Status:

Version 1

Abstract

Figures

Introduction

Methodology

Study design:

Study setting

Information sources

Search strategy

Selection process

Data collection process and items

study risk of bias

Subgroup analysis

Results

1. Description of the Included Studies

2. Risk of Bias within the included Studies

3.1. Parkinson Disease Questionaire-39:

3.2. Total Unified Parkinson’s Disease Rating Scale (UPDRS)

3.3. Berg Balance Scale (BBS)

3.5. Six-Minute Walk Test (6 MWT)

3.6. Gait:

3.7. self reported falls:

3.8. Cognitive and psychological assessment

Discussion

Study strength

Study Limitations

Future recommendation

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1