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

Journal of NeuroEngineering and Rehabilitation volume 22, Article number: 80 (2025) Cite this article

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.

Graphical abstract

Introduction

Deep brain stimulation (DBS) is an established treatment for Parkinson’s disease (PD) [1], with subthalamic nucleus (STN) being the most common surgical target [2]. Although a number of clinical studies suggests long-term improvement in symptoms such as tremor, rigidity, and akinesia [1], the effect of stimulation on motor axial (e.g., postural instability, trunk posture alterations) and gait impairments (e.g., freezing of gait–FOG) is still unclear [3, 4]. Patients might experience no improvement over time [3, 4], even when stimulation parameters are optimized for appendicular symptoms [1, 3].

Physical therapy (PT) is currently included in the multidisciplinary treatment of PD, but not specifically for patients treated with DBS [5, 6]. PT aims to optimize independence, safety, well‐being, and ultimately quality of life, with systematic reviews and meta-analyses confirming PT-induced improvement in motor and non-motor PD impairments [7–9]. In particular, PT effectively complements pharmacological treatment to improve postural stability [7, 10], gait [11, 12], and those symptoms resistant to dopaminergic replacement (e.g. axial motor dysfunctions, FOG) [13, 14] in people with PD (PwPD). Additionally, rehabilitative motor training stimulates a number of neuroplasticity-related events in PwPD [15], including neuronal growth, synaptogenesis, neurotrophic factor expression, and neurogenesis [16–18]. Therefore, PT has the potential to be an effective adjuvant treatment to optimize motor outcomes after deep brain stimulation of the subthalamic nucleus (STN-DBS) surgery. However, this additive effect has not yet been systematically assessed-instead, DBS patients are frequently excluded from exercise trials [19, 20]. Although the current recommendations allow the return to exercise within weeks following surgery, there is no explicit indication for PT [21] and rehabilitative care in clinical settings is led by the personal expertise of physical therapists. Only some insights of safety and effectiveness are currently available, but the studies are characterized by poor methodological rigor and great variability. Therefore, no solid scientific knowledge (e.g., guidelines) is currently available.

Given the potential added value of PT to STN-DBS treatment and the current lack of knowledge, the integration of clinical findings and the experience of leading experts might serve to boost the opening of this field of clinical research and to shape lines of research in it. With these aims, we first performed a systematic scoping review of the articles assessing PT programs in PwPD treated with DBS to summarize the current findings. Then, we asked internationally recognized clinical and academic DBS experts to comment on them and other aspects in a Delphi method-based study [22].

Methods

In this work, we first performed a systematic scoping review to gather the current knowledge on PT protocols in PwPD with DBS. On the basis of the collected results and on the European Physiotherapy Guideline for Parkinson’s Disease [23], we created a 5-point Likert scale questionnaire regarding the role of PT and PT interventions in PwPD with DBS to be answered by clinically and academically experienced DBS clinicians.

Systematic scoping review

A systematic scoping review of clinical research articles was performed according to previous studies, since this type of review allows for a broad overview of topics [24–26]. The literature search was conducted in PubMed/MEDLINE, with the following search keywords: (“deep brain stimulation” OR “DBS”) AND (“physiotherapy” OR “physical therapy” OR “motor rehabilitation” OR “rehabilitation” OR “training” OR “exercise”) AND (“Parkinson’s disease” OR “PD”). We considered only clinical studies on PwPD with DBS written in English and published from January 1st, 1994, to June 30th, 2024. Reviews, protocols, simulation studies, conference abstracts or editorials were excluded. Given the paucity of studies on this topic, we decided not to restrict the inclusion criteria further, e.g., considering PwPD who underwent DBS surgery regardless the surgical target (e.g., STN or GPi). After removing duplicates, two independent reviewers (MG and NVM) screened the results of the search based on the titles and abstracts, and then evaluated the full texts of the selected articles. Conflicts were resolved by consensus, if necessary.

The following data were extracted from the selected studies: author, year of publication, study design, characteristics of the subjects, DBS protocol and duration, PT protocol, outcomes and main results. Although the need for quality assessment of selected studies in scoping reviews has been questioned [25], some authors suggest that it improves clarity [27]. Therefore, we performed a quality assessment of the selected studies through the modified version of the Downs and Black checklist [28] (see Table 1 in the Supplementary Materials), which assigns each article a score and evaluation (total score: 11–13, excellent; total score: 9–10, good; total score: 7–8, fair; total score: ≤ 6, poor).

Questionnaire development

As previously proposed [29], the questionnaire was based upon an extensive review of the literature and the European Physiotherapy Guideline for Parkinson’s Disease [23]. From the systematic scoping review, we defined a taxonomy of the outcome measures, and related each of them to an improvement area, and a taxonomy of the PT proposed in published studies. Given the frequency of anatomical targets (STN and GPi) for DBS surgery and treatment in the studies considered in the systematic scoping review (88% STN-DBS, 0.7% GPi-DBS; 11.3% undefined), we decided to refer only to STN-DBS for the creation of the questionnaire for the Delphi panel. Then, a Steering Committee (SC) of experts (n = 6) selected within the collaborative network of the leading authors discussed the topics and created a structured questionnaire using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree) [22]. To do so, the concepts identified in the two taxonomies were translated into two sections of the questionnaire: one is more general and focuses on the opportunity and potential benefits of PT for PwPD receiving STN-DBS; the other, which focuses on the different PT treatments (see Table 2 in Supplementary Materials).

Delphi methodology

The Delphi technique is a multiphase procedure that combines personal viewpoints into a general consensus within a group (panel) [30]. A series of structured questionnaires (rounds) are anonymously completed by experts (panelists) and the responses from each questionnaire fed back in summarized form to the participants [31]. This allows the panelists to reassess their initial judgments, considering the positive aspects of interacting groups (e.g., inclusion of different backgrounds) without the negative ones (e.g., influence of dominant members) [32]. For the purpose of our study, a modified Delphi process [29] was created in three rounds as previously recommended [31]. In rounds one, two and three, the SC together with a broader Experts Panel (EP = 15) conducted quantitative assessments to reach a consensus. Electronic questionnaires were utilised in all steps of the process. To prevent confirmation bias, if a statement reached a consensus in either the first or second round, it was not included in the following round; conversely, statements that did not reach a consensus were included in the following round.

The consensus process is mediated by a “facilitator” who was in charge of coordinating the rounds and providing a summary of the responses that should encourage the experts to rethink their scoring. Despite the absence of guidelines, we considered a “consensus reached” when > 80% of the responses fell within the same response label [22]. Since there is no precise standard for defining an “expert” [33], we chose to involve positional leaders in the scientific field (including neurologists, neurosurgeons, physiotherapists) based on the number of peer-reviewed publications [34, 35], as recommended by prior studies [22]. We considered a response rate of > 70% for each round to preserve the rigor of the technique [36]. To highlight the strength of support through each round, we reported the results of each round separately in both textual (median ± IQR) [32] and graphical representations [33]. As a further analysis, we decided to transform the 5-point Likert scale object of the main analysis into a 3-point Likert scale, i.e., to consider the two highest (4 = agree; 5 = strongly agree) and lowest (1 = strongly disagree; 2 = disagree) points as two points (agree and disagree, respectively), while keeping the middle point (undecided). This secondary analysis was performed only for the results of the third round.

Results

Systematic scoping review

Our search yielded 632 articles (Fig. 1 in the Supplementary Materials). Of those, 615 were excluded after reviewing titles and abstracts, while 17 were further assessed as full texts for eligibility. Of these, only 12 met our inclusion criteria [37,38,39,40,41,42,43,44,45,46,47,48]. The characteristics of the included studies are summarised in Table 1. One was a case series [47], seven were pilot clinical studies [39, 40, 42–46], two were retrospective studies [37, 38], and two were case-controlled studies [41, 48], for a total of 279 patients enrolled. No randomized controlled trials (RCTs) were found. Of these, 245 had STN-DBS (169 bilateral, 76 not specified), 2 had bilateral GPi-DBS, and 32 had DBS with no specified anatomical target. The number of participants per study ranged between 1 [47] and 73 [37], with four studies involving > 20 participants [37, 39, 44, 48]. The mean age of participants ranged from 57.6 [44] to 67.6 [43] years, with a mean baseline disease severity ranging from 19.1 (UPDRS, part III) [41] to 105.5 (MDS-UPDRS, part III) [48] and a mean disease duration ranging from 10.5 [46] to 18.8 [43]. Only five studies reported the characteristics of the stimulation [38, 39, 41, 43, 46], and seven studies did not specify the duration of DBS treatment before PT treatment [37–39, 41, 45–47]. As for quality assessment, two studies [44, 48] were classified as presenting good methodological quality, six [37–39, 41–43] as fair, and four [40, 45–47] as poor, according to the Modified Downs and Black Quality Assessment Checklist (see Table 3 in the Supplementary Materials). In general, the studies met the criteria regarding the reporting section, however, a few studies [39, 40, 45–47] did not report the actual probability values of the results, and none provided estimates of random variability for the main outcomes or reported the characteristics of patients lost to follow-up. Owing to the limited sample size, external validity could not be guaranteed for most of the articles. With respect to internal validity, no one clearly stated the potential use of data dredging.

Table 1 Studies investigating physical therapy programs in patients with Parkinson’s disease and deep brain stimulation
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PT outcomes and areas of assessment

The effect of PT interventions was evaluated through various outcomes across the studies, which assessed both motor/functional, biomechanical (e.g., gait analyses) and neurophysiological (e.g., EEG) changes (Table 1). The selected studies examined the role of the PT in PwPD undergoing DBS in 5 main areas of assessment: (I) Motor symptoms and motor decline, as assessed mainly through the UPDRS—part III, including its different scores (e.g., axial score and gait score), or the MDS-UPDRS; (II) Gait performance, as assessed mainly though TUG and gait analyses; (III) Balance and postural instability, as assessed mainly though the BBS and the Mini-BESTest; (IV) Quality of life or activities of daily living, as assessed mainly though the FIM and PDQ-39; and (V) Timing of PT treatment, in terms of the number of months after neurosurgery. Although half of the selected studies did not report the time between surgery and rehabilitation [37–39, 45–47], three considered patients with chronic stimulation (e.g., several years) [41, 43, 48], whereas two patients had only a few months of DBS (< 1 year) [40, 42]. One study [44] enrolled patients with different timings [44]. As shown in Table 2 in the Supplementary Materials, these areas of assessment were used to build the questionnaire for the Delphi panel.

PT treatments

PT treatments and protocols varied considerably across the selected studies (Table 1). Most of them studied the effect of aerobic training with mobility, stretching, strengthening, balance and gait exercises or a combination thereof [38, 39, 43, 44, 46], whereas four [37, 45, 47, 48] considered a multidisciplinary approach. Among them, only one study [48] reported a clear description of the characteristics of the interventions. Three studies assessed the use of treadmill training: one [40] associated with body weight and robotic support, one [42] with body weight support and physical therapy (stretching, strengthening and balance exercises), and one [41] with rhythmic auditory stimulation. Similarly, PT protocols markedly differed in terms of intensity, frequency, and duration. Only three studies reported the intensity (i.e., session length) of the treatment [38, 39, 48], which ranged from 40 to 60 min. The frequency ranged from twice weekly for 8 weeks [42] to twice a day weekly for 4 weeks [43, 48], for a total duration ranging from 2 [38, 39] to 8 [42, 44, 46] weeks.

Delphi panel results

For the SC, 7 authors were invited but only 6 agreed to participate (response rate: 85.7%). For the EP, of the 20 authors identified, 2 declined to participate and 3 did not reply (response rate: 75%). Therefore, the overall number of the panellists was 21 (overall response rate: 77.7%-see Table 4 in the Supplementary Materials), which is within the recommended range [32]. Demographic characteristics of the panellists are displayed in Table 5 in the Supplementary Materials. Briefly, most of them were male (81%), between 50 and 59 years old (47.6%) and highly experienced (95.2% and 85.7% with > 10 years of experience in neurostimulation field and DBS clinical trials, respectively).

For the 11 general considerations on PT (Table 2), the first round led to no consensus for any of the statements (Fig. 2 in the Supplementary Materials); in the second round, the consensus was reached in three statements (Fig. 1); and finally, in the third round, the consensus was reached in four additional statements (Fig. 2). In the second round, the panellists strongly agreed that PT might help improve motor symptoms (Statement 1) and quality of life (Statement 4) of PwPD undergoing STN-DBS, recommending physical therapists to be part of the multidisciplinary équipe taking care of the patients (Statement 11) (for all, 89% strongly agreed, median ± IQR: 5 ± 0). After the third round, the panellists strongly agreed on the need to prescribe PT to PwPD implanted with STN-DBS as soon as the clinical conditions are stable (Statement 8–94% strongly agreed, median ± IQR: 5 ± 0) and to chronically-implanted patients (Statement 9–88% strongly agreed, median ± IQR: 5 ± 0), because it might help maximize the effects of stimulation (Statement 5–88% strongly agreed, median ± IQR: 5 ± 0). Finally, they suggested that PT be prescribed in treatment guidelines as complementary treatment for PwPD treated with STN-DBS (Statement 10–88% strongly agreed, median ± IQR: 5 ± 0).

Table 2 Five-point Likert questionnaire with the results (median ± IQR) for each round
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Fig. 1
figure 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

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Fig. 2
figure 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

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The secondary analysis performed on the third round of answers revealed an agreement on three further statements (Fig. 3 in the Supplementary Materials). Specifically, the experts agreed that PT treatments suggested in the literature for postural instability (Statement 2–94% agreed) and gait disability (Statement 3–88% agreed) for PwPD could also be useful for PwPD under STN-DBS treatment; similarly, they agreed that PT could alleviate the burden of caregivers taking care of these patients (Statement 7–88% agreed).

For the 28 statements on PT treatments (Table 2), no consensus was reached after the first and second rounds (Fig. 4, 5 in the Supplementary Materials). After the third round, consensus was reached in three statements (Fig. 3). Indeed, the panellists agreed on the prescription of conventional PT (i.e., physiotherapist-supervised active exercise interventions targeting gait, balance, transfers or physical capacity, or a combination thereof) as soon as the clinical conditions of the implanted patients are stable (Statement 12–81% strongly agreed, median ± IQR: 5 ± 0) and in chronically-implanted patients (Statement 13–81% strongly agreed, median ± IQR: 5 ± 0). Additionally, massage or manual therapy was discouraged as treatment for chronically implanted patients (Statement 17–81% disagreed, median ± IQR: 2 ± 0).

Fig. 3
figure 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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The secondary analysis performed on the third round of answers revealed an agreement on several other statements (Fig. 6 in the Supplementary Materials). Specifically, the experts agreed that PwPD implanted with STN-DBS, regardless of time, should be prescribed cognitive movement strategies (Statement 24–100% agree; Statement 25–100% agree), aerobic training (Statement 26–94% agree; Statement 27–94% agree), muscle strengthening (Statement 28–81% agree; Statement 29–81% agree), and exercise to improve trunk and limb flexibility and range of motion (Statement 38–88% agree; Statement 39–88% agree). Conversely, the experts did not recommend robot-assisted gait training (Statement 30–81% disagree; Statement 31–94% disagree) and massage or manual therapy as soon as the clinical conditions are stable (Statement 16–81% disagree).

Discussion

To answer the question of the use of PT in PwPD receiving STN-DBS, in this study, after summarizing the current scientific knowledge, we asked the opinion of clinical and academic DBS experts applying a Delphi methodology. The 21 experts agreed that PT might maximize the effects of stimulation, improving both motor symptoms and quality of life. PT should be prescribed in treatment guidelines in the form of conventional physiotherapy (i.e., physiotherapist-supervised active exercise interventions targeting gait, balance, transfers or physical capacity, or a combination thereof), and physical therapists should be part of the multidisciplinary équipe taking care of PwPD implanted with STN-DBS. However, massage or manual therapy should not be suggested.

PT or no PT?

Considering the caveats and methodological limitations found in the systematic scoping review, it might be only qualitatively argued that PT for PwPD treated with STN-DBS could improve dynamic and static balance [38, 39, 41, 44, 45, 48], gait performance [38–44] and posture [43], ultimately leading to a significant decrease in the daily number of falls [43] and the fear of falling [41], with an increase in motor performance [37, 39, 41, 44, 45, 48], functional independence [37, 44, 48], and quality of life [45]. Therefore, our expert consensus is highly important for establishing whether PT should be potentially beneficial for PwPD treated with STN-DBS. The experts agreed that PT might improve motor symptoms and quality of life, maximizing the effects of electrical stimulation. Additionally, in our secondary analysis, the experts considered that PT could be helpful for caregivers, and that PT treatments already suggested for postural instability and gait disability in PwPD could also be effective for PwPD receiving STN-DBS, in line with the limited number of clinical studies [38–44, 46, 48].

Although STN-DBS has been demonstrated to be highly effective at controlling motor symptoms in PwPD [49], some clinical issues remain open. After initial improvement following STN-DBS [50, 51], postural instability [52] and gait disturbances [53, 54] have been reported to worsen over time [55]. Some findings even suggest no significant improvement in trunk rigidity [56]. Although it is not clear whether this deterioration might be due to PD progression rather than DBS treatment, taken together, this worsening might determine physical inactivity, increase in falls [57], and secondary complications [58] after STN-DBS surgery. On the other hand, solid scientific knowledge confirms that PT maximizes independence, well‐being, and quality of life [59, 60], in addition to improving motor (such as postural instability [7, 10], gait impairments such as festination, FOG [13, 14]) and non-motor (e.g., depression, apathy, and fatigue [8, 9]) PD symptoms. It is reasonable to hypothesize that this evidence in the general PD population would also apply to PwPD implanted with STN-DBS, where exercise and STN-DBS might exert a complimentary, positive effects on PD severity and mobility. This coupled effect has already been shown for exercise and dopaminergic medication on muscle force production, UPDRS III scores, and mobility in PwPD [61]. Finally, both STN-DBS [62] and PT [15] were suggested to stimulate a number of neuroplastic and neuroprotective biochemical events in PwPD. For example, while STN-DBS could preserve nigral dopamine neurons from degeneration [63, 64] and increase the level of neurotrophic factors in the nigrostriatal system and primary motor cortex [65], PT and exercise would increase neuronal growth, synaptogenesis, neurotrophic factor expression, and neurogenesis [16–18]. The combination of STN-DBS and PT in PwPD could boost these neurochemical mechanisms and biological pathways, attenuating disease progression and enhancing compensatory neuronal strategies. However, all these assumptions remain speculative, and no data are available—which is likely why experts couldn’t reach an agreement on this.

PT prescription

The panel agreed that PT should be prescribed for PwPD implanted with STN-DBS, both in post-acute and chronic phases. Additionally, they suggested that PT should be included in treatment guidelines, and that physical therapists should be involved in the multidisciplinary team in charge of patients. The low-risk nature of PT coupled with the potential benefit for improving motor function and quality of life in PwPD with STN-DBS supports these statements. According to the studies selected in our systematic scoping review, PT in these patients might be well tolerated–although the duration of the rehabilitation period might be an obstacle for completion [40]. Additionally, PT appears to be safe, with several studies reporting no intervention-related adverse effects [41, 42]. For example, Bestaven et al. [43] reported that, despite initial doubts and apprehension, all the enrolled subjects agreed with and completed the PT protocol. Also, current recommendations allow patients to return to exercise within weeks following surgery [66]; therefore, it appears that PT should be considered a nonharmful intervention for PwPD with STN-DBS, even more so because PT is commonly a supervised treatment. Indeed, physical therapists could contribute to the care of patients after implantation surgery (e.g., in the management of complications after surgery [67] or during the adaptation of stimulation parameters [67]) or in the chronic phase (e.g., modifying pathological movement patterns [68] or teaching patients to adapt motor strategies and relevant activities of daily living to the new conditions [68]). In addition to the technical aspects of intervention, PT treatment characteristically requires multiple sessions for quite long periods—a time where patient-therapist relationship can be developed for explanations or counselling. This could represent an occasion to increase the cooperation and motivation of patients and caregivers, which is fundamental to achieve a good outcome after DBS [69].

PT protocols

Despite the very limited scientific knowledge found in the systematic scoping review, the panellists agreed that conventional PT should be prescribed to PwPD implanted with STN-DBS, regardless of the time from surgery. Interestingly, when the experts’ opinions were reconsidered on a 3-point Likert scale, several PT treatments were also considered effective for PwPD receiving STN-DBS—cognitive movement strategies, aerobic training, muscle strengthening, and exercise to improve trunk and limbs flexibility and range of motion.

The results on conventional PT-like interventions [38, 39, 42–44, 46, 48] as shown by our systematic scoping review, suggest a positive effect on motor and functional PD symptoms. A number of findings suggest similar effects for the general PD population [9], although without superiority over other types of treatment [70]. For example, several studies suggest that multifactorial conventional PT interventions including muscle strengthening, increasing of range of movement, balance training and gait training have positive effects on balance dysfunction and postural instability in PwPD [15, 71]. Additionally, balance training improves self-confidence while performing activities of daily living and reduces the fall rate [21], whereas gait training improves FOG, gait speed and step length, even months after the treatment [11, 14]. PwPD with STN-DBS implants might benefit from the same evidence observed in the general PD population. In addition, robust evidence suggests that other recommended PT treatments reduce PD motor symptom severity and improve motor function in PwPD [72–75]. Recently, various forms of aerobic training (treadmill walking, stationary cycling) have shown to slow motor progression in PwPD who are not yet on dopaminergic medication [76, 77].

On the other hand, the panellists agreed that massage or manual therapy should not be applied in chronically implanted patients, nor should robot-assisted gait training be recommended. While no evidence is currently available in PwPD treated with STN-DBS, a systematic review suggests that the evidence in the general PD population is limited and conflicting in some cases due to methodological concerns [78]. The European Physiotherapy Guideline for Parkinson’s disease released a weak recommendation for using massage or manual therapy to reduce pain and muscular spasms, but highlighted the need to always combine it with other types of interventions as no evidence supports their use to improve physical and functional performance [23]. Conversely, the literature reports encouraging results [38, 40–42] of robot-assisted gait training, including in PwPD [79].

Rehabilitative considerations

In PwPD under STN-DBS treatment, motor [80, 81] and functional [82] strategies established in years of disease need to be readapted after the rapid changes induced by the stimulation. This requires the active involvement of the patient in a rehabilitation pathway to optimize the benefits of DBS. For example, pathological movement patterns typical of gait in PD [83] need to be gradually adapted to improve the mobility achieved by STN-DBS [68]. Additionally, since STN-DBS is a symptomatic but not resolutive treatment, PwPD receiving STN-DBS might need PT treatment during their lifetime. It was proposed that general motor rehabilitation principles studied for PwPD, such as personalizing motor strategies and applying motor learning techniques (e.g., repetition, task-specific training) [84], are applicable to those PwPD undergoing DBS [68]. However, some differences from the general PD population critical for PT programs might be considered:

  1. I.

    Pre-surgery characteristics of the patients. PwPD candidates for STN-DBS surgery have a confirmed diagnosis of idiopathic PD, are young (younger than 69 years but may be older) and have no or little cognitive dysfunction [69, 85]. From a pharmacological point of view, these patients strongly respond to dopamine medication and have complications of levodopa therapy (e.g., dyskinesias, on–off fluctuations) [85, 86]. These criteria create a particular subgroup of the PD population, whose characteristics must be considered when planning PT interventions.

  2. II.

    Actual clinical characteristics of the patients. A new, DBS-induced phenotype of PD was proposed, where tremor, rigidity, bradykinesia, on–off fluctuations and dyskinesias are well-controlled, but gait impairments, postural instability and abnormalities are still present [49]. Therefore, these should be the primary targets of PT interventions. In addition, stimulation-induced side effects need to be considered, such as dysphagia [3] and speech disorders (e.g., dysarthria) [87], cognitive (e.g., alteration of verbal fluency) [88, 89], psychological (e.g., impulsivity, depression) [90] and autonomic (e.g., constipation, swallowing) [90, 91] impairments. Besides motor rehabilitation, also other rehabilitative health professions [91] (e.g., speech therapy, occupational therapy, neuropsychology) could be involved and treatment tested.

  3. III.

    Presence of hardware. A systematic review of hardware-related complications of DBS reported that lead migration or dislocation (0–19% of interventions) and fracture or failure of some parts of the DBS system (0–15% of interventions) are among the most common complications after DBS surgery [57, 92]. Therefore, although PT programs appear to be safe, a more intensive research program must consider hardware presence and frailty. In addition, the use of any physical forces (e.g., magnetic fields) that could interfere with DBS components should be avoided.

  4. IV.

    Interaction between stimulation and PT. In light of the opportunities given by advanced DBS technologies [93, 94] such as adaptive DBS [95], it is likely that patients might need specific DBS programming while undergoing PT sessions to increase their performance and optimize benefits. This should be a further research topic to be considered as physiotherapists and DBS experts interact to develop effective and personalized rehabilitation programs.

Limitations

The panel conclusions should not be viewed as a replacement for clinical judgment or original research; rather, our results are relevant mostly in terms of future research directions, which will foster the development of the field of rehabilitation after STN-DBS in PwPD. Indeed, they are based on the collective expertise of a panel of experts who can draw on both their personal experience and scientific knowledge—even more so that our panel was gender- and nation- imbalanced (majority was male, and all experts coming from North America or Europe). Consensus-based results provide only a level 4 evidence being expert opinions [96, 97], which represents the lowest level of evidence [98]. Also, one should consider that our panel was geographically. More discussion and empirical evidence coming from methodologically precise studies (e.g., RCTs) are needed to support the feasibility of our results, especially considering that other common stimulation targets (e.g., the GPi) were not considered in this study.

Conclusion

Despite the limited, low-quality knowledge currently available on the role of PT in PwPD and STN-DBS, the panellists agreed that PT could improve the motor symptoms and quality of life of these patients and should be considered as part of management in the form of conventional PT, as part of the management guidelines. In conclusion, the PT is a safe intervention that can prescribed to PwPD receiving STN-DBS to maximize clinical improvements. Even though providing only level 4 evidence, this Delphi consensus represents a call to both the motor rehabilitation (but also occupational, speech and neuropsychological) and DBS community to start working and interacting to deepen this field of research. Well-designed and well-performed clinical trials (e.g., blinded RCT) could provide high-level evidence for PT, for example verifying whether current guidelines are applicable to this population or whether specific treatments can be of support clinical care, which for years has been relegated to the personal expertise of physical therapists despite the increasing number of PwPD implanted with STN-DBS.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

DBS:

Deep brain stimulation

PD:

Parkinson’s disease

STN:

Subthalamic nucleus

STN-DBS:

Deep brain stimulation of the subthalamic nucleus

GPi:

Globus pallidus internus

GPi-DBS:

Deep brain stimulation of globus pallidus internus

FOG:

Freezing of gait

PT:

Physical therapy

PwPD:

People with Parkinson’s disease

SC:

Steering committee

EP:

Experts panel

UPDRS:

Unified Parkinson’s Disease Rating Scale

MDS-UPDRS:

Movement Disorder Society—Unified Parkinson’s disease rating scale

TUG:

Timed up and go

BBS:

Berg balance scale

Mini-BESTest:

Mini Balance Evaluation Systems Test

FIM:

Functional Independence Measure

PDQ-39:

Parkinson’s Disease Questionnaire—39

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Acknowledgements

The authors acknowledge Dr. Briselda Doka, who contributed to the early stages of the literature research and data handling.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and 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

    Matteo Guidetti, Sara Marceglia, Tommaso Bocci, Natale V. Maiorana, Serena Oliveri & Alberto Priori

  2. 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

    Tommaso Bocci, Serena Oliveri & Alberto Priori

  3. School of Medicine, Program in Physical Therapy, Washington University in St. Louis, St. Louis, MO, USA

    Ryan Duncan

  4. School of Medicine, Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA

    Ryan Duncan

  5. Krembil Research Institute, University Health Network, Toronto, ON, Canada

    Alfonso Fasano & Andres M. Lozano

  6. CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, Toronto, ON, Canada

    Alfonso Fasano & Andres M. Lozano

  7. KITE, University Health Network, Toronto, ON, Canada

    Alfonso Fasano

  8. 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

    Alfonso Fasano

  9. Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, 3011 SW Williston Rd, Gainesville, FL, 32608, USA

    Kelly D. Foote

  10. Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA

    Kelly D. Foote

  11. Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada

    Clement Hamani

  12. Harquail Centre for Neuromodulation, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada

    Clement Hamani

  13. Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada

    Clement Hamani

  14. Department of Neurosurgery, Hannover Medical School, Hannover, Germany

    Joachim K. Krauss & Andrea A. Kühn

  15. Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany

    Andrea A. Kühn

  16. Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany

    Andrea A. Kühn

  17. NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany

    Andrea A. Kühn

  18. DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany

    Andrea A. Kühn

  19. Berlin School of Mind and Brain, Humboldt-Universität Zu Berlin, Berlin, Germany

    Andrea A. Kühn

  20. Department of Medicine and Health, University of Molise, 86100, Campobasso, Italy

    Francesco Lena

  21. IRCCS INM Neuromed, 86077, Pozzilli, Italy

    Francesco Lena, Nicola Modugno & Marco Santilli

  22. Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK

    Patricia Limousin

  23. Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Andres M. Lozano

  24. Division of Neurology, CHU of Grenoble, Grenoble Institute of Neurosciences, INSERM U1216, Grenoble Alpes University, Grenoble, France

    Elena Moro

  25. Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA

    Michael S. Okun

  26. Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, USA

    Michael S. Okun

  27. Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany

    Alfons Schnitzler

  28. Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany

    Alfons Schnitzler

  29. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands

    Yasin Temel

  30. Department of Neurology, University Hospital of Marburg, Marburg, Germany

    Lars Timmermann

  31. Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany

    Veerle Visser-Vandewalle

  32. Department of Neurology, University Hospital Würzburg, Würzburg, Germany

    Jens Volkmann

Authors
  1. Matteo Guidetti
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  2. Sara Marceglia
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  3. Tommaso Bocci
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  4. Ryan Duncan
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  5. Alfonso Fasano
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  6. Kelly D. Foote
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  7. Clement Hamani
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  8. Joachim K. Krauss
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  9. Andrea A. Kühn
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  10. Francesco Lena
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  11. Patricia Limousin
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  12. Andres M. Lozano
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  13. Natale V. Maiorana
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  14. Nicola Modugno
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  15. Elena Moro
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  16. Michael S. Okun
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  17. Serena Oliveri
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  18. Marco Santilli
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  19. Alfons Schnitzler
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  20. Yasin Temel
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  21. Lars Timmermann
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  22. Veerle Visser-Vandewalle
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  23. Jens Volkmann
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  24. Alberto Priori
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Contributions

M.G., F.L., M.S., A.P., N.M., and R.D. performed the conceptualization. M.G., S.M., T.B., N.V.M., F.L., M.S., A.P., N.M., R.D., A.S., A.F., A.A.K., A.M.L., C.H., E.M., J.V., J.K.K., K.D.F., L.T., S.O., M.S.O., P.L., V.V.V., and Y.T performed the investigation. M.G. and S.M. drafted and wrote the main manuscript text. M.G., S.M., and N.V.M. performed the experimental data acquisition and statistical analysis. M.G. prepared the result visualization. A.P. and S.M. were responsible for validation, reviewing, and editing the original work. M.G., S.M., T.B., N.V.M., F.L., M.S., A.P., N.M., R.D., A.S., A.F., A.A.K., A.M.L., C.H., E.M., J.V., J.K.K., K.D.F., L.T., S.O., M.S.O., P.L., V.V.V., and Y.T reviewed and edited the original work. All authors read and approved the submitted version of the manuscript.

Corresponding author

Correspondence to Sara Marceglia.

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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.

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Guidetti, M., Marceglia, S., Bocci, T. et al. Is physical therapy recommended for people with parkinson’s disease treated with subthalamic deep brain stimulation? a delphi consensus study. J NeuroEngineering Rehabil 22, 80 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12984-025-01616-w

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Keywords

Journal of NeuroEngineering and Rehabilitation

ISSN: 1743-0003

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