ambiguous. They do not sufficiently follow the PICO .... a clinical or healthcare-related question, which is ... research question, the PICO model allows translation.
PM R 10 (2018) 560-563
www.pmrjournal.org
Letters to the Editor
Comments on: “Nordic Walking for the Management of People With Parkinson Disease: A Systematic Review” To the Editor: Cugusi et al [1] recently conducted a systematic review to evaluate the effects of Nordic walking on motor and nonmotor symptoms, functional performance, and quality of life in people with Parkinson disease. Investigating the effect of physical activity and exercise may help to better understand the impact of these interventions on physical and mental health in patients with Parkinson disease. I wish to comment on some procedures and findings in this review. First, the authors assessed the quality of the included randomized clinical trials (RCTs) by using the Physiotherapy Evidence Database (PEDro) scale. However, 2 of included studies that were scored 6 in PEDro did not match critical items, such as concealed allocation and intention-to-treat analysis. A greater score on PEDro is not sufficient to consider high quality of evidence, especially for the RCTs that compared physical activity or exercise with other interventions, pharmacologic intervention, or no interventions. The included articles have better possibility to match blinding patients and therapists. The adaptation of more precise approaches, such as Grading of Recommendations Assessment, Development and Evaluation approach, is highly recommended to determine the level of evidence. Second, the review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. However, the inclusion criteria are ambiguous. They do not sufficiently follow the PICO format (ie, P: participants, I: intervention, C: comparison, O: outcomes). The authors state the inclusion criteria as people with Parkinson disease; an analysis of the main outcomes arising from mid- to long-term (defined as 2 weeks); and Nordic walking program, and the study design was an RCT. The authors state that their review aims to analyze the effects of Nordic walking compared with other exercise interventions on M.A. Disclosure: nothing to disclose
motor and nonmotor symptoms, functional performance, and quality of life in people with Parkinson disease. Surprisingly, the inclusion criteria do not demand that the studies compare Nordic walking with other exercise interventions, and the included studies measure motor symptoms, nonmotor symptoms, functional performance, and quality of life. The included articles were RCTs that compared the effect of Nordic walking with different types of exercise such as (Nordic treadmill walking, treadmill training, walking program, home-based exercise program, and flexibility and relaxation training) or conventional care alone. Finally, previous studies suggest that exercise improves some of the cardinal features of Parkinson disease that often are resistant to pharmacologic intervention, including gait, posture, and dysarthria [2-4]. In addition, studies in animals on aerobic exercise for Parkinson disease suggest that exercise does provide a protective effect on the brain with Parkinson disease [5]. Thus, we believe that exercise should be considered in the treatment regimen for all patients with Parkinson disease who do not have specific contraindications. Mohammad Alwardat, PT, PhD School of Neuroscience University of Rome "Tor Vergata" Rome, Italy https://doi.org/10.1016/j.pmrj.2018.01.007
References 1. Cugusi L, Manca A, Dragone D, et al. Nordic walking for the management of people with Parkinson disease: A systematic review. PM R 2017;9:1157-1166. 2. Jo ¨ bges EM, Spittler-Schneiders H, Renner CI, Hummelsheim H. Clinical relevance of rehabilitation programs for patients with idiopathic Parkinson syndrome. II: Symptom-specific therapeutic approaches. Parkinsonism Relat Disord 2007;13: 203-213. 3. Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner WJ, for the Quality Standards Subcommittee of the American
1934-1482/$ - see front matter ª 2018 by the American Academy of Physical Medicine and Rehabilitation
Letters to the Editor / PM R 10 (2018) 560-563 Academy of Neurology. Practice parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review) [Erratum appears in Neurology 2006;67:299]. Neurology 2006; 66:976-982. 4. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of exercise interventions for people with Parkinson’s
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disease: A systematic review and meta-analysis. Mov Disord 2008; 23:631-640. 5. Tillerson JL, Caudle WM, Revero ´n ME, Miller GW. Exercise induces behavioral recovery and attenuates neurochemical deficits in rodent models of Parkinson’s disease. Neuroscience 2003;119:899-911.
Reply to comment on: “Nordic Walking for the Management of People with Parkinson Disease: A Systematic Review” To the Editor: We are pleased to respond to the letter by Dr Mohammad Alwardat, who raised some issues about the methodology and conclusions of our recent publication, titled “Nordic Walking for the Management of People With Parkinson Disease: A Systematic Review” [1]. We believe that there may have been some misinterpretation on Dr Alwardat’s part, and by this reply we wish to clarify any concern to Dr Alwardat’s and to PM&R readers’ satisfaction. The first concern of Dr Alwardat regarded the use of the Physiotherapy Evidence Database (PEDro) scale to assess the risk of bias of the included studies. The PEDro scale is the reference tool in systematic reviews and meta-analyses to evaluate the methodologic quality of physiotherapy trials [2-4]. All the studies that were eligible for our review were available in the PEDro database (www.pedro.org.au); consequently, their PEDro scores did not need to be calculated. Thus, the assessment of the study quality and the interpretation of the scores carried out in our review paper [1] are adequately justified. Regarding the evaluation of the level of evidence, Dr Alwardat also pointed out that in our review we should have used the Grading of Recommendations Assessment, Development and Evaluation system. However, because of the high heterogeneity that we observed across the studies, not only in the exercise interventions but also in the outcome measures used, the Grading of Recommendations Assessment, Development and Evaluation approach, which rates the quality of evidence across the trials by specific and shared outcomes [5], could not be used.
L.C. Disclosure: nothing to disclose P.S. Disclosure: nothing to disclose C.S. Disclosure: nothing to disclose M.M. Disclosure: nothing to disclose G.M. Disclosure: nothing to disclose A.M. Disclosure: nothing to disclose D.D. Disclosure: nothing to disclose F.D. Disclosure: nothing to disclose
The second concern raised by Dr Alwardat relates to “insufficient application of the PICO model.” PICO stands for Patient, Problem or Population, Intervention, Comparisons, and Outcomes and is considered the reference model to frame and attempt to answer a clinical or healthcare-related question, which is crucial to retrieve clinically relevant evidence in the literature [6]. By helping to define the foreground research question, the PICO model allows translation of a clinical question into a searchable query. The PICO format is recommended and helpful, but its application in total is not mandatory because it should be based on the specific needs and aims of the research to be performed, which in turn help to refine the question and the search query [6,7]. The methodologic approach to the PICO framework used in our review [1] is in agreement with the U.S. National Library of Medicine, which recommends to clearly spell out the Patient/Problem/Population and the Intervention, whereas the inclusion of data on Comparisons and Outcomes is at the discretion of the researcher. Accordingly, the National Library of Medicine PICO search labels Comparisons and Outcomes as “optional” (https://pubmedhh.nlm.nih.gov/nlmd/pico/ piconew.php). As a further consideration, while focusing and refining the research question and the search query is highly advisable for widely and extensively studied topics that have been investigated by a considerable number of articles, this approach may be problematic in cases of niche arguments for which literature searches can retrieve only a handful of papers, which is the case of Nordic walking for Parkinson disease. In this circumstance, maintaining the focus of the search a little bit wider may prevent one to unwittingly exclude precious records. Finally, we could not agree more with Dr Alwardat on his point that exercise is a powerful and effective tool to deal with disabilities in individuals with Parkinson disease without specific contraindications, as clearly shown by a series of studies from our research group [8-10]. However, data from individual studies, although promising and obtained in well-controlled experimental
