. 2025 Apr 10;22(1):80.

doi: 10.1186/s12984-025-01616-w.

Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study

Matteo Guidetti¹, Sara Marceglia², Tommaso Bocci^{1

3}, Ryan Duncan^{4

5}, Alfonso Fasano^{6

7

8

9}, Kelly D Foote^{10

11}, Clement Hamani^{12

13

14}, Joachim K Krauss¹⁵, Andrea A Kühn^{15

16

17

18

19

20}, Francesco Lena^{21

22}, Patricia Limousin²³, Andres M Lozano^{6

7

24}, Natale V Maiorana¹, Nicola Modugno²², Elena Moro²⁵, Michael S Okun^{26

27}, Serena Oliveri^{1

3}, Marco Santilli²², Alfons Schnitzler^{28

29}, Yasin Temel³⁰, Lars Timmermann³¹, Veerle Visser-Vandewalle³², Jens Volkmann³³, Alberto Priori^{1

3}

Affiliations

¹ Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, MI, Italy.
² Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, MI, Italy. sara.marceglia@unimi.it.
³ Clinical Neurology Unit, "Azienda Socio-Sanitaria Territoriale Santi Paolo e Carlo", Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy.
⁴ School of Medicine, Program in Physical Therapy, Washington University in St. Louis, St. Louis, MO, USA.
⁵ School of Medicine, Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA.
⁶ Krembil Research Institute, University Health Network, Toronto, ON, Canada.
⁷ CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, Toronto, ON, Canada.
⁸ KITE, University Health Network, Toronto, ON, Canada.
⁹ Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, 3011 SW Williston Rd, Gainesville, FL, 32608, USA.
¹¹ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
¹² Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
¹³ Harquail Centre for Neuromodulation, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
¹⁴ Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.
¹⁵ Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
¹⁶ Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁷ Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany.
¹⁸ NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁹ DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany.
²⁰ Berlin School of Mind and Brain, Humboldt-Universität Zu Berlin, Berlin, Germany.
²¹ Department of Medicine and Health, University of Molise, 86100, Campobasso, Italy.
²² IRCCS INM Neuromed, 86077, Pozzilli, Italy.
²³ Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.
²⁴ Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
²⁵ Division of Neurology, CHU of Grenoble, Grenoble Institute of Neurosciences, INSERM U1216, Grenoble Alpes University, Grenoble, France.
²⁶ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA.
²⁷ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA.
²⁸ Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁹ Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
³⁰ Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.
³¹ Department of Neurology, University Hospital of Marburg, Marburg, Germany.
³² Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³³ Department of Neurology, University Hospital Würzburg, Würzburg, Germany.

PMID: 40211348
PMCID: PMC11987424
DOI: 10.1186/s12984-025-01616-w

Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study

Matteo Guidetti et al. J Neuroeng Rehabil. 2025.

. 2025 Apr 10;22(1):80.

doi: 10.1186/s12984-025-01616-w.

Authors

Affiliations

¹ Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, MI, Italy.
² Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, MI, Italy. sara.marceglia@unimi.it.
³ Clinical Neurology Unit, "Azienda Socio-Sanitaria Territoriale Santi Paolo e Carlo", Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142, Milan, Italy.
⁴ School of Medicine, Program in Physical Therapy, Washington University in St. Louis, St. Louis, MO, USA.
⁵ School of Medicine, Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA.
⁶ Krembil Research Institute, University Health Network, Toronto, ON, Canada.
⁷ CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, Toronto, ON, Canada.
⁸ KITE, University Health Network, Toronto, ON, Canada.
⁹ Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, 3011 SW Williston Rd, Gainesville, FL, 32608, USA.
¹¹ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
¹² Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
¹³ Harquail Centre for Neuromodulation, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
¹⁴ Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.
¹⁵ Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
¹⁶ Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁷ Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany.
¹⁸ NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁹ DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany.
²⁰ Berlin School of Mind and Brain, Humboldt-Universität Zu Berlin, Berlin, Germany.
²¹ Department of Medicine and Health, University of Molise, 86100, Campobasso, Italy.
²² IRCCS INM Neuromed, 86077, Pozzilli, Italy.
²³ Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.
²⁴ Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
²⁵ Division of Neurology, CHU of Grenoble, Grenoble Institute of Neurosciences, INSERM U1216, Grenoble Alpes University, Grenoble, France.
²⁶ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA.
²⁷ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA.
²⁸ Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁹ Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
³⁰ Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.
³¹ Department of Neurology, University Hospital of Marburg, Marburg, Germany.
³² Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³³ Department of Neurology, University Hospital Würzburg, Würzburg, Germany.

PMID: 40211348
PMCID: PMC11987424
DOI: 10.1186/s12984-025-01616-w

Abstract

Background: Although deep brain stimulation of the subthalamic nucleus (STN-DBS) induces motor benefits in people with Parkinson's disease (PwPD), its effect on motor axial symptoms (e.g., postural instability, trunk posture alterations) and gait impairments (e.g., freezing of gait) is still ambiguous. Physical therapy (PT) effectively complements pharmacological treatment to improve postural stability, gait performance, and other dopamine-resistant symptoms (e.g. freezing of gait) in the general population with PD. Despite the positive potential of combined PT and STN-DBS surgery, scientific results are still lacking. We therefore involved worldwide leading experts on DBS and motor rehabilitation in PwPD in a consensus Delphi panel to define the current level of PT recommendation following STN-DBS surgery.

Methods: After summarizing the few available findings through a systematic scoping review, we identified clinically and academically experienced DBS clinicians (n = 21) to discuss the challenges related to PT following STN-DBS. A 5-point Likert scale questionnaire was used and based on the results of the systematic review, thirty-nine questions were designed and submitted to the panel-half related to general considerations on PT following STN-DBS, and half related to PT treatments.

Results: Despite the low-to-moderate quality of data, the few available rehabilitation studies suggested that PT could improve dynamic and static balance, gait performance and posture in the population with PD receiving STN-DBS. Similarly, the panellists strongly agreed that PT might help improve motor symptoms and quality of life, and it may be prescribed to maximize the effects of stimulation. The experts agreed that physical therapists could be part of the multidisciplinary team taking care of the patients. Also, they agreed that conventional PT, but not massage or manual therapy, should be prescribed because of the specificity of STN-DBS implantation.

Conclusions: Although RCT evidence is lacking, upon Delphi panel, PT for PwPD receiving STN-DBS can be potentially useful to maximize clinical improvement. However, more research is needed, with RCTs and well-designed studies. The rehabilitation and DBS community should expand this area of research to create guidelines for PT following STN-DBS.

Keywords: DBS; Deep brain stimulation; Delphi consensus; Motor rehabilitation; Movement disorders; Neuromodulation; Parkinson’s disease; Physical therapy; Physiotherapy.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: A.F. has received payments as consultant and/or speaker from Abbott, Boston Scientific, Ceregate, Inbrain Neuroelectronics, Medtronic, Iota and has received research support from Boston Scientific, Medtronic; K.D.F. reports receiving research support and fellowship support from Medtronic and Boston Scientific and research support from Functional Neuromodulation; J.K.K. is a consultant to Medtronic, Boston Scientific, aleva and Inomed; A.A.K. is a consultant to Medtronic, Boston Scientific and Teva; A.M.L. is a consultant to Abbott, Boston Scientific, Insightec, Medtronic and Functional Neuromodulation (Scientific Director). EM has received an educational grant from Boston Scientific and honoraria from Medtronic and Newronika; M.S.O. serves as Medical Advisor in the Parkinson’s Foundation, and has received research grants from NIH, Parkinson’s Foundation, the Michael J. Fox Foundation, the Parkinson Alliance, Smallwood Foundation, the Bachmann-Strauss Foundation, the Tourette Syndrome Association, and the UF Foundation. M.S.O. 's research is supported by: R01 NS131342 NIH R01 NR014852, R01NS096008, UH3NS119844, U01NS119562. M.S.O. is PI of the NIH R25NS108939 Training Grant. M.S.O. has received royalties for publications with Hachette Book Group, Demos, Manson, Amazon, Smashwords, Books4Patients, Perseus, Robert Rose, Oxford and Cambridge (movement disorders books). M.S.O. is an associate editor for New England Journal of Medicine Journal Watch Neurology and JAMA Neurology. M.S.O. has participated in CME and educational activities (past 12–24 months) on movement disorders sponsored by WebMD/Medscape, RMEI Medical Education, American Academy of Neurology, Movement Disorders Society, Mediflix and by Vanderbilt University. The institution and not M.S.O. receives grants from industry. M.S.O. has participated as a site PI and/or co-I for several NIH, foundation, and industry sponsored trials over the years but has not received honoraria. Research projects at the University of Florida receive device and drug donations; A.S. received consulting fees from Abbott, Zambon, and Abbvie, and speaker honoraria from bsh medical communication, Abbott, Kyowa Kirin, Novartis, Abbvie, and Alexion, GE Healtcare. The institution of A.S., not A.S. personally, received funding by the Deutsche Forschungsgemeinschaft, the Brunhilde Moll Foundation, and Abbott; L.T. received occasional payments as a consultant for Boston Scientific, L.T. received honoraria as a speaker on symposia sponsored by Boston Scientific, AbbVIE, Novartis, Neuraxpharm, Teva, the Movement Disorders Society und DIAPLAN. The institution of L.T., not L.T. personally, received funding by Boston Scientific, the German Research Foundation, the German Ministry of Education and Research, the Otto-Loewi-Foundation and the Deutsche Parkinson Vereinigung. Neither L.T. nor any member of his family holds stocks, stock options, patents or financial interests in any of the above-mentioned companies or their competitors. L.T. serves as the president of the German Neurological Society without any payment or any income; V.V.V. received occasional payments as a consultant or speaker on symposia from Boston Scientific and Medtronic. J.V. reports grants and personal fees from Medtronic, grants and personal fees from Boston Scientific, personal fees from Abbott outside the submitted work. J.V. was supported by the German Research Foundation (DFG, Project-ID424778381, TRR 295)—J.V. received consulting and lecture fees from Boston Scientific, Medtronic and Newronika, research grants from the German Research Foundation, the German Ministry of Research and Education, Boston Scientific and Medtronic, lecture Honoraria from UCB, Zambon, Abbott; A.P. and S.M. are founders and shareholders of Newronika Spa, Italy; All the other authors declare no competing interests.

Figures

**Fig. 1**
Percentage of agreement for the 11 general considerations on physical therapy after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 1–11) among the Delphi Panel members, as result of the second round. Statement 1, Statement 4 and Statement 11 reached a consensus, i.e., 89% of the responses fell within the response label “strongly agree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement

**Fig. 2**
Percentage of agreement for the 11 general considerations on physical therapy after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 1–11) among the Delphi Panel members, as result of the third round. Statement 5, Statement 8, Statement 9 and Statement 10 reached a consensus, i.e., respectively, 88%, 94%, 88% and 88% of the responses fell in the response label “strongly agree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement

**Fig. 3**
Percentage of agreement for the 28 statements on physical therapy treatments after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 12–39) among the Delphi Panel members, as result of the third round. Statement 12 and Statement 13 reached a consensus, i.e., for both, 81% of the responses fell in the response label “strongly agree”. Statement 17 reached a consensus, i.e., 81% of the responses fell in the response label “disagree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statemen

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Update of

Physical therapy in patients with Parkinson's disease treated with Deep Brain Stimulation: a Delphi panel study.
Guidetti M, Marceglia S, Bocci T, Duncan R, Fasano A, Foote KD, Hamani C, Krauss JK, Kühn AA, Lena F, Limousin P, Lozano AM, Maiorana NV, Modugno N, Moro E, Okun MS, Oliveri S, Santilli M, Schnitzler A, Temel Y, Timmermann L, Visser-Vandewalle V, Volkmann J, Priori A. Guidetti M, et al. medRxiv [Preprint]. 2024 Sep 23:2024.09.20.24314037. doi: 10.1101/2024.09.20.24314037. medRxiv. 2024. Update in: J Neuroeng Rehabil. 2025 Apr 10;22(1):80. doi: 10.1186/s12984-025-01616-w. PMID: 39399050 Free PMC article. Updated. Preprint.

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Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study

Affiliations

Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study

Authors

Affiliations

Abstract

Conflict of interest statement

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Update of

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