Parkinson's Disease Treatment



Parkinson's Disease TreatmentA Literature ReviewValerie Salazar and Katie ScanlonState University of New York Institute of TechnologyParkinson's Disease Treatment A Literature ReviewParkinson’s disease (PD) is a progressive neurological condition caused by the degeneration of dopamine-producing neurons in the subtantia nigra region of the brain (Lindop, 2012). Dopamine is responsible for relaying messages in the brain to control movements, specifically smooth coordinated movements (Desilets & LaFontaine, 2013). The progressive damage of neurons and dopamine-producing cells, or neurodegeneration, is believed to be the pathology experienced by those with PD (Casey, 2013). PD symptoms begin gradually, often unilaterally, and worsen with time (Parkinson’s Disease Foundation, 2014). Main motor symptoms include bradykinesia, rigidity, resting tremors and postural instability (Lindop, 2012). Impacts of patients’ activities of daily living include difficulty walking, talking, or even feeding one-self. Non-motor symptoms can present as emotional or behavioral changes, problems with cognition and memory, sleep disorders, sexual dysfunction, and sensory deterioration including incontinence, color vision perception, and decreased sense of smell (Simon, 2012). Relevance to nursingThe progression and treatment of PD varies patient to patient. Advanced Practice Registered Nurses (APRNs) play a critical role in the coordination and provision of services as they are ideally placed to assess, discuss, and address the multitude of issues presented above (Osborne, 2009). The use of holistic assessments, treatments, and education provided by APRNs is beneficial to PD patients and their families as they provide consistent, high quality levels of judgment, discretion, and decision-making regarding clinical care (Osborne, 2009). Purpose statementThe purpose of this paper is to provide a review of recent literature regarding the treatments available for PD specifically pharmacologic, non-pharmocologic, and deep brain stimulation options. The authors will discuss the current state of the science in terms of PD treatments including gaps in the literature and recent research studies. The selected published studies and peer reviewed articles will be discussed to provide insight to emerging treatments and expanding research for PD. A literature review grid can be found in Appendix A. MethodA conventional literature search was undertaken by the authors through the State University of New York Institute of Technology’s Cayan Library website and their home internet services using Google Scholar. The phrases “Parkinson’s Management” and “Parkinson's Treatment” were entered using the CINAHL, Medline, and Health Source: Nursing/Academic Edition databases. Resources were included if they were published after 2009, in English, and available in full text without additional cost to the researchers. Papers with both qualitative and quantitative research studies were included. Selection criteria for data collection focused on peer reviewed articles and research studies published in nursing academic journals. Books and book chapters were not selected. Our initial search revealed 1,830 sources. These results were narrowed to 227 after applying the above criteria to our searches. The final selection was based on reading abstracts and selecting the most pertinent material.ResultsMotor SymptomsNon-pharmacological treatment. PD adversely affects an individual's ability to maintain balance while standing. As the disease progresses, the individual has difficulty managing their activities of daily life, experience postural instability, have an increased risk of falls, and have a dysfunctional gait (Li et al., 2012). Li et al., (2012), conducted a study to examine if tai chi would improve postural stability in PD patients. 195 patients, ages 40-85 with stage 1-4 on the Hoehn and Yahr staging scale were divided into groups and received either tai chi, stretching, or resistance-training (Li et al., 2012). Primary outcomes included improvement in the limits-of-stability test from baseline. The secondary outcomes were measured by using the Unified PD Rating Scale (UPDRS) and included measuring gait and strength, functional-reach, and times up and go tests. Falls were also included as part of the secondary outcomes (Li et al., 2012).The study concluded that the tai chi training improved postural stability, reduced the incidence of falls, increased gait speed, and stride length. Tai chi also appears to reduced dyskinesia (Li et al., 2012). Participants who received the tai chi training performed consistently better in maximum excursion and directional control in comparison to the stretching and resistance-training groups. The tai chi participants also performed better in the secondary outcomes and falls than the stretching group. Stride length and functional reach were performed better by the tai chi group participants when compared with the resistance-training group, but did not lower the incidence of falls when compared to the resistance-training group (Li et al., 2012). Li et al., (2012), also determined that improvements after tai chi training were maintained at three months after training.Vivas, Arias, & Cudeino (2011), also conducted a study on the effects physical therapy has on PD. The authors examined the effects of land and aquatic therapy on postural stability and self-movement in PD. Eleven men and women with an average age of 67 received similar exercises through land or aquatic therapy (Vivas, Arias, & Cudeino, 2011).Evaluations were completed when patients were on off-dosing of their medications. Functional Reach Test, Berg Balance Scale, gait, Timed Up and Go test, and the Unified PD Rating Scale were the main evaluation tools utilized by Vivas, Arias, and Cudeino (2011). This small study concluded that the aquatic therapy was more effective on postural stability than the land based therapy in patients with PD (Vivas, Arias, & Cudeino, 2011). Tomilinson et al., (2012) completed a meta-analysis, which reviewed the use of physiotherapy intervention in the treatment of PD. After reviewing 39 randomized controlled trials, the researchers concluded that the studies reported a benefit of physiotherapy for gait speed, two or six minute walking test, freezing of gait questionnaire, times up and go test, functional reach test, Berg balance scale, and UPDRS. However, physiotherapy did not appear to benefit patient rated quality of life (Tomilinson et al., 2012).The researchers determined physiotherapy has short term benefits in the treatment of PD. The studies demonstrated that multiple forms of physiotherapy are used in the treatment of PD, with there being little difference in effect between the different types of physiotherapy (Tomilinson et al., 2012). The results of the meta-analysis conducted by Tomilinson et al., (2012), supports the experimental results of Li et al., (2012) and Vivas, Arias, & Cudeiro (2011), that tai chi and aquatic therapy, both forms of physiotherapy are beneficial improvements in motor symptoms of PD. Surgical treatment. The surgical procedure of choice for those with advanced PD is deep-brain stimulation. Follett et al., (2010) and Schuepbach et al., (2013) conducted studies examining the effects of deep brain stimulation in the patients with PD.Follett et al., (2010), randomly assigned 299 PD patients to undergo pallidal or subthalamic stimulation and compared 24 month outcomes. Motor function was the primary motor function assessed on the UPDRS part III, when patients were not receiving anti-parkinson pharmacotherapy, but receiving stimulation. Self-reported function, quality of life, neurocognitive function, and adverse events were secondary outcomes measured in the study (Follett et al., 2010). Results of the study conducted by Follett et al., (2010) demonstrated that there was not a significant difference between pallidal and subthalamic stimulation in motor function, self-reported function, or adverse events. Those undergoing subthalamic stimulation required dogaminergic agents at a lower dose than the PD patients undergoing pallidal stimulation (Follett et al., 2010). The visuomotor component of processing speed was found to have declined more after subthalamic stimulation when compared to pallidal stimulation. Levels of depression improved after pallidal stimulation, however, there was a worsening of depression following subthalamic stimulation (Follett et al., 2010)Schuepbach et al., (2013), conducted a two year study, which randomly assigned patients with PD with early motor complications to receive neurostimulation in addition to medical therapy or only medical therapy. This research study concluded that subthalamic stimulation in PD patients was superior to medical therapy in motor disability, activities of daily living, motor complications caused by levodopa, and time with good mobility and no dyskinesia (Schuepbach, et al., 2013). Schuepbach et al., (2013), found that although subthalamic stimulation was superior to medical therapy, there is a greater risk of adverse events related to the surgical procedure than just medical therapy, but there is a risk of adverse events for medical therapy as well.Pharmacological treatment.Medications are available to help in the treatment of motor symptoms related to PD, however, even with the availability of these medications, motor fluctuations remain common for those with advanced PD (Hauser et al., 2013). Hauser et al., (2013), conducted a phase 3, double-blind, randomized trial comparing immediate and extended release carbidopa-levodopa in PD patients who scored a 1-4 on the Hoehn and Yahr disability scale. Participants must also have been diagnosed with PD after the age of 30, taking levodopa daily at least four times a day at a dosage of at least 400 mg daily, and experiencing 2.5 hours of off time a day, and could be taking additional Parkinson's medication if the dosage was stable (Hauser et al., 2013).Hauser et al., (2013), concluded that the extended-release carbidopa-levodopa patients experienced a greater reduction in off-time than those patients who received the immediate-release medication (Hauser et al., 2013). The extended-release carbidopa-levodopa may be useful in PD patients with motor fluctuations and reduce dosing frequency, but there are also downfalls to the extended-release form of carbidopa-levodopa. Extended-release carbidopa-levodopa have a longer time between when the medication is started, a decrease in motor fluctuations is noticed by the patient, increased dyskinesia, and there is less predictability of response in comparison to immediate-release carbidopa-levodopa (Hauser, et al., 2013). There may be a complex pharmacotherapy schedule that a PD patient may have to follow to control their symptoms. Lack of adherence to complex dosing schedules leads to less effective control of PD symptoms (Schapria et al., 2013). Hauser et al., (2013), examined the use of extended versus immedicate release carbidopa-levodopa in the treatment of PD and Schapria et al., (2013) examined patient preference of once a day or three time a day (tid) dosing of pramipexole. Results of the Hauser et al., (2013) and Schapria et al., (2013) may help improve compliance of a complex medication schedule for PD.Schiapria et al., (2013) determined from 374 survey responders, that early and advanced PD patients preferred the once daily dosing versus tid dosing of pramipexole. However, this study only examined patient preference in the number of daily doses, not the efficacy of treatment (Schiapria et al., 2013).Catalan et al., (2013) conducted a study examining levodopa in a different form than that in the study conducted by Hauser et al., (2013). Catalan et al., (2013) assessed the effect jejunal levodopa infusion had on advanced stage PD patient's motor complications, severe impulsivity, and dopamine dysregulation syndrome (DDS), which were not controlled by oral medications. Patients were given the levodopa infusion for 15 hours a day and reassessed at 25 (+/- 9 weeks). Catalan et al., (2013), found that off-periods and dyskinesias decreased with the levodopa infusion compared to baseline. All patients experienced a near complete resolution of symptoms of DDS and impulse control behaviors with the levodopa infusion therapy (Catalan et al, 2013).Non-motor SymptomsTroeung, Egan, and Gasson (2013) conducted a meta-analysis of randomized placebo trials for PD patients with depression and/or anxiety. Two trials found that non-pharmacological treatment had a significant effect on depression in patients with PD. However, Troeung, Egan, and Gasson (2013), found that the studies they reviewed regarding pharmacological treatment of depression and/or anxiety improved symptoms, but the results were found to be non-significant. Dementia is a complication that PD patients may face during the course of the disease. Rivastigmine has been approved in the United States for the treatment of PD dementia (PDD) and Alzheimer's disease. Impaired executive function, core symptoms of PDD, is part of the cognitive change that occurred with PD (Schmitt, Farlow, Meng, Tekin, & Olin, 2010). Schmitt et al., (2010), conducted a randomized controlled study where 541 patients received rivastigmine or a placebo treatment. Those who received the rivastigmine treatment experienced significant improvements on the Letter Fluency test, Card Sorting, and had fewer self-corrected errors on the Color-word Interface, which were the assessment tools utilized to evaluate each participant. The results of this study indicate that rivastigmine may be beneficial in individuals with PDD (Schmitt el al., 2010).Study LimitationsA majority of the studies conducted regarding the treatment of motor and non-motor symptoms of PD have small sample sizes and have short follow-up time frames (Tomlinson et al., 2012). In this literature review, the largest sample population was from the study conducted by Schmitt et al. (2010), who were recruited from multiple countries around the world. The studies utilized in this literature review also reflects the short follow-up time frames. The study conducted by Follett et al. (2010), examined pallidal stimulation versus subthalamic stimulation in the treatment of motor symptoms had a follow-up time frame of two years, which was the longest follow-up time of this literature review.Gaps in the LiteratureThe majority of patients seen in medical offices have multiple serious illnesses. The majority of studies exclude individuals who have serious medical illnesses in addition to PD, which makes it difficult to apply research results to patients who have serious comorbidities (MetaWork Inc. Evidence-base Practice Center, 2003). Research studies should also include participants of different races, ethnic groups, and ages because the results would then not be limited to a small population of individuals with PD (MetaWork Inc. Evidence-base Practice Center, 2003). The research studies included in this literature review, which included Li et al., (2012), Vivas, Arias, & Cudeino (2011), Tomilinson et al., 2012, Follett et al., (2010), & Hauser et al., (2013), support these gaps in the literature through their limited age ranges, lack inclusion of different minorities, and not including individuals who have chronic illnesses in addition to PD.Family members are an important aspect in managing the health of PD patients. The perception of the caregiver should be included in studies as this may play a role in the management of care (MetaWork Inc. Evidence-base Practice Center, 2003). Troeung, Egan, and Gasson (2013) found that there is limited research utilizing controlled trials that examine the use of pharmacotherapy and non-pharmacological treatment of depression and anxiety in PD patients. The lack of research studies limits the evidence to support the use of a specific treatment in PD patients with depression and/or anxiety (Troeung, Egan, & Gasson, 2013).ConclusionPD is the second most common neurodegenerative disease in the world (Haahr, Kirkevold, Hall, & Ostergaard, 2011) and affects between one to two percent of the population over age 65 (Casey, 2013). Progression of the disease, and responses to treatments, vary from case to case requiring a close relationship between patients, families, and their health care providers (Osborne, 2009). Providing care for patients with PD requires a detailed understanding of the course of illness, treatment options, and recent developments in research (Casey, 2013). Living with PD can be unpredictable, and patients experience a loss of physical, psychological, and social characteristics (Haahr, Kirkevold, Hall, & Ostergaard, 2011).This literature review revealed optimal PD management converges non-pharmacological, pharmacological, and surgical interventions to best support the patient's overall well-being. As a cure for PD is not yet available, maintenance of the patient's symptoms and quality of life is the target for the APRN's plan of care. Further research about treatment options is necessary as PD symptoms can impact every aspect of a patient's life in an unpredictable and progressive manner. APRNs can provide PD care by means of personalized attention to patients and caregivers as the disease progresses. A multidisciplinary team approach offering integrated care is important for care management (Lindop, 2012). The APRN's role is to provide close clinical monitoring and treatment adjustment while bestowing personal support to patients and families.ReferencesCasey, G. (2013). Parkinson's disease: A long and difficult journey. Kai Tiaki Nursing New Zealand, 19(7), 20-24. Catalan, M. J., de Pablo-Fernandex, E., Villanueva, C., Fernandex-Diez, S., Lapena-Montero, T., Garcia-Ramos, R., & Lopez-Valdes, E. (2013). Levodopa infusion improves impulsivity and dopamine dysregulation syndrome in parkinson's disease. Movement Disorders, 28(14), 2007-2010. doi: 10.1002/mds.25636 Follett, K. A., Weaver, F. M., Stern, M., Hur, K., Harris, C. L., Luo, P., Marks, W. J., Rothlin, J., Sagher, O., Moy, C., Pahwa, R., Burchiel, K., Hogarth, P., Lai, E. C., Duda, J. E., Holloway, K., Samii, A., Horn, S., Bronstein, J. M., Stoner, G., Starr, P. A., Simpson, R., Baltuch, G., De Salles, A., Huang, G. D., & Reda, D. J. (2010). Pallidal versus subthalamic deep-brain stimulation for parkinson's disease. The New England Journal of Medicine, 362(22). 2077-2091. doi: 10.1056/NEJMoa0907093Haahr, A., Kirkevold, M., Hall, E. Oc, & Ostergaard, K. (2010). Living with advanced Parkinson's disease: A constant struggle with unpredictability. Journal of Advanced Nursing, 67(2), 408-417. Hauser, R. A., Hsu, A., Kell, S., Espay, A. J., Sethi, K., Stacy, M., Ondo, W., O'Connell, M., & Gupta, S. (2013). Extended-release carbiopa-levodopa (IPX066) compared with immediate-release carbidopa-levodopa in patients with parkinson's disease and motor fluctuations: A phase 3 randomised, double-blind trial. Lancet Neurology, 12(4), 346-356. doi: 10.1016/S1474-4422(13)70025-5 Li, F., Hamer, P., Fitzgerald, K., Eckstrom, E., Stock, R., Galver, J., Maddalozzo, G., & Batya, S.S. (2012). Tai chi and postural stability in patients with parkinson's disease. The New England Journal of Medicine, 366(6), 511-519.Lindop, F. (2012). A multidisciplinary approach to Parkinson's disease. British Journal of Neuroscience Nursing, 8(2), 61-64. MetaWork Inc. Evidence-base Practice Center. (2003). Diagnosis and treatment of parkinson’s disease: A systematic review of the literature. Retrieved from , L. (2009). Marking 20 yearsof Parkinson's disease nurse specialists: Looking to the future. British Journal of Neuroscience Nursing, 5(10), 450-454. Schapira, A. H. V., Barone, P., Hauser, R. A., Mizuno, Y., Rascol, O., Busse, M., Debieuvre, C., Fraessdorf, M., & Poewe, W. (2013). Patient-reported convenience of once-daily versus three-times-daily dosing during long-term studies of pramipexole in early and advanced parkinson's disease. European Journal of Neurology, 20(1), 50-56. doi: 10.1111/j.1468-1331.2012.03712.x Schmitt, F. A., Farlow, M. R., Meng, X., Tekin, S., & Olin, J. T. (2010). Efficacy of rivastigmine on executive function in patients with parkinson’s disease dementia. CNS Neuroscience & Therapeutics, 16(6), 330-336. doi: 10.1111/j.1755-5949.2010.00182.x Schuepbach, W. M. M., Rau, J., Jnudsen, K., Volkmann, J., Krack, P., Timmermann, L., Halbig, T. D., Navarro, S. M., Meier, N., Falk, D., Mehdorn, M., Paschen, S., Maarouf, M., Barbe, M. T., Fink, G. R., Kupsch, A., Gruber, D., Scheider, G. H., Seigneuret, E., Kistner, A., Chaynes, P., Ory-Magne, F., Brefel Courbon, C., Vesper, J., Schnitzler, A., Wojtecki, L., Houeto, J. L., Bataille, B., Maltete, D., Damier, P., Raoul, S., Sixel-Doering, F., Hellwig, D., Gharabaghi, A., Kruger, R., Pinsker, M. O., Amtage, F., Regis, J. M., Witjas, T., Thobois, S., Mertens, P., Kloss, M., Hartmann, A., Oertel, W. H., Post, B., Speeiman, H., Agid, Y., Schade-Brittinger, C., & Deuschl, G. (2013). Neurostimulation for parkinson's disease with early motor complications. The New England Journal of Medicine, 368(7). 610-622. doi: 10.1056/NEJMoal1205158 Tomlinson, C. L., Patel, S., Meek, C., Herd, C. P., Clarke, C. E., Stowe, R., Shah, L., Sackley, C., Deane, K. H. O., Wheatley, K., & Ives, N. Physiotherapy intervention in parkinson's disease: Systematic review and meta-analysis. British Medical Journal, 345(e5004). doi: 10.1136/bmj.e5004 Troeung, L., Egan, S. J., & Gasson, N. (2013). A meta-analysis of randomised placebo-controlled treatment trials for depression and anxiety in parkinson’s disease. PloS One, 8(11). doi: 10.1371/journal.pone.0079510 Vivas, J., Arias, P., & Cuderio, J. (2011). Aquatic therapy versus conventional land-based therapy for parkinson's disease: An open-label pilot study. Archives of Physical Medicine and Rehabilitation, 92(8), 1202-1211. doi: 10.1016/j.apmr.2011.03.017.Appendix AStudiesFocusSubjectsPopulationAgeMethodFindingsCatalan, et al., (2013)Use of levodopa infusion in advanced stage Parkinson's disease patients in the treatment of impulsivity and dopamine dysregulation syndrome (DDS) that were not controlled with oral medicationN = 24Patient's with severe Parkinson's disease, disabling motor fluctuations and dyskinesiaAverage age 67.9 yearsQuazi-experimentalLevodopa infusion decreased the off-periods and dyskinesias decreased when compared to baseline in advanced stage Parkinson's disease patients. All patients experienced a near complete resolution of symptoms of DDS and impulse control behaviors with the levodopa infusion therapy.Follett et al., (2010)Pallidal stimulation versus subthalamic stimulation in patients with advanced Parkinson's diseaseN =299pallidal stimulation (152 patients)Subthalamic stimulation (147 patients)Patient's with Parkinson's disease in stage 2 or higher on the Hoehn and Yahr disability scale, had a response to levodopa, had persistent and disabling symptoms despite optimal medical treatment, poor motor function or symptom control for 3 out of 24 hours, and having been receiving medical treatment but having no changes in therapy in the last monthAt least 21 yearsRandomized Controlled TrialQuantitative experimentalThere was no significant difference in change in motor function between pallidal stimulation and subthalamic stimulation. Of the secondary outcomes there was no statistical difference between the surgical procedures in self-reported function and adverse events. Lower doses of dopamine were required and a decline in a component of processing speed was observed in those who undergoing subthalamic stimulation. Depression worsened following subthalamic stimulation and improved following pallidal stimulation.Hauser et al., (2013)Comparing immediate-release and extended-release carbidopa-levodopa on motor fluctuations in Parkinson's patientsN = 393(201 extended-release)(192 immediate-release)Parkinson's disagnosis after age of 30, stage 1-4 on the Hoehn and Yahr disability scale, mini-mental status exam score of 26, stable regimen of immediate-release levodopa, average of 2.5 hrs off time per day.No age providedRandomized Controlled double-blind trialQuantitative experimentalEtended-release carbidopa-levodopa patients experienced a greater reduction in off-time than those patients who received the immediate-release medication. The extended-release medication also reduces the dosing frequency of levodopa.Li et al., (2012)Comparing tai chi, resistance training and stretching to improve postural stability. N = 195Parkinson's disease patients in stage 1-4 on the Hoehn and Yahr staging scale, at least one score of 2 or more in the motor section of the Unified Parkinson's Disease Rating Scale, stable medication use, able to stand unaided or walk with or without assistive device.40-85 yearsRandomized Controlled TrialQuantitative experimentalTai chi appeared to improve maximum excursion and directional control in comparison with resistance-training and stretching. The tai chi group out performed the stretching group in all secondary outcomes and lowered the incidence of falls when compared to the stretching group. The tai chi group also preformed better than the resistance-training group in stride length and functional gait, but did not lower the incidence of falls when compared to the resistance-training group.Schapira, et al., (2013)Patient preference of once daily versus three times a day dosing of pramipexole in early or advanced Parkinson's diseaseN = 374 (number who completed trail and survey)Parkinson's disease patients, initially at stage 1-3 on the Hoehn and Yahr staging scale, diagnosed within in the last 5 years, diagnosed at or after the age of 30No age givenQuazi-experimentalBoth early and advanced stage Pakinson's patients found that once a day dosing was more convenient than three times a day dosing. This study only looked at convenience and not treatment efficacy.Schmitt et al., (2010)Rivastigmine versus placebo treatment for dementia in Parkinson's patientsN = 541Individuals with Parkinson's disease dementia Average age 72.7 yearsRandomized Controlled TrialQuantitative experimentalRivastigmine was found to be superior than the placebo on the executive function tests, which evaluates planning, problem solving, and flexibility of thinking those patients with dementia related to Parkinson's disease.Schuepbach et al., (2013)Use of subthalamic stimulation and medical therapy or medical therapy alone in the treatment of early motor complications in Parkinson's diseaseN = 251Parkinson's disease patient age 18-60; have had Parkinson's for at least 4 years; rating of below stage 3 on the Hoehn and Yahr staging scale when on medication; improving motor signs on dopaminergic medications; fluctuations or dyskinesia for 3 years of less; mild to moderate impairment in social and occupation functioning, or score of more than 6 on the UPDRS II for activities of daily livingAverage age of 52(Age 18-60)Randomized Controlled TrialQuantitative experimentalSubthalamic stimulation in was superior to medical therapy in motor disability, activities of daily living, motor complications caused by levodopa, and time with good mobility and no dyskinesia in Parkinson's patients. There is a greater risk of adverse events with subthalamic stimulation than medical therapy alone.Tomlinson et al., (2012)Analysis of different types of physiotherapy in the treatment of Parkinson's diseaseN = 39 Randomized controlled trials comparing physiotherapy with no intervention No age givenMeta-analysisPhysiotherapy has short term benefits in the treatment of Parkinson's disease. The studies demonstrated that multiple forms of physiotherapy are used in the treatment of Parkinson's disease. There is little difference in the effects of the different types of physiotherapy. Troeung, Egan, & Gasson (2013)Meta-analysis of placebo-controlled randomized trials in treating depression and/or anxiety in Parkinson's patientsN = 9 studiesRandomized placebo-controlled trials on treatment of depression and anxiety in Parkinson's patientsNo age givenMeta-analysisTwo trials found that non-pharmacological treatment had a significant effect on depression in patients with Parkinson's disease. The studies reviewed regarding pharmacological treatment of depression and/or anxiety improved symptoms, but the results were found to be non-significant. Vivas, Arias, & Cudeiro (2011)Comparing aquatic and land based therapy on postural stability and self-movement in Parkinson's patientsN = 11Parkinson's disease patients in stages 2-3 on the Hoehn and Yahr staging scale while in off-staging medication phase, and no dementia, Average age 67 plus or minus 5.5 yearsRandomized Controlled TrialQuantitative experimentalBoth the land and aquatic therapy groups demonstrated improvements on the Functional Reach Test, while only the aquatic group showed improvements in the Berg Balance Scale and the Unified Parkinson's Disease Rating Scale. The aquatic group demonstrated a significantly larger improvement in postural stability after therapy than the land based treatment group. ................
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