Understanding Low Back Pain in Individuals with Parkinson’s Disease: a Scoping Review of Physiotherapy Interventions

Autori

Sara Borghi [Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum – University of Bologna, Bologna, Italy] [Department of Physical Medicine and Rehabilitation, Azienda USL Bologna, Ospedale di Bentivoglio, Bologna, Italy]

Angelo Russo [Physical Therapy and Rehabilitation Unit, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy]

Mattia Longo [Bachelor in Physiotherapy – Alma Mater Studiorum – University of Bologna, 40138 Bologna (BO)]

Lorenzo D’Orio [Bachelor in Physiotherapy – Alma Mater Studiorum – University of Bologna, 40138 Bologna (BO)]

Francesco Giuseppe Materazzi [Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum – University of Bologna, Bologna, Italy] [Montecatone Rehabilitation Institute, Imola (BO), Italy]

Background and aims

Low back pain (LBP) is a common and disabling symptom in persons with Parkinson’s Disease (PwPD), resulting from complex interactions between neurodegeneration, sensory dysfunction, and motor impairments. Effective management requires personalized, multimodal physiotherapy addressing biomechanical, neuromuscular, and neuroplastic factors. The aim of the present scoping review is to explore current evidence on physiotherapy interventions for LBP in Parkinson’s disease.

Methods

This scoping review was performed and reported according to the PRISMA-ScR guidelines. MEDLINE, Embase, Scopus, Cochrane Library and PEDro were searched up to May 23rd 2025. To be included, studies must involve participants diagnosed with PD at any stage, describe or evaluate at least one physiotherapy or physical intervention, and assess LBP as an outcome. There were no restrictions on study design; records were excluded if they were not published in Italian or English. Data extraction was performed using RAYYAN QCRI online software by two blinded reviewers; a third one was involved in case of disagreements.

Results

A total of 6832 records were obtained by the bibliographic search; after deleting duplicates, the remaining 4598 citations were screened by two blinded reviewers. Eight studies met the eligibility criteria: 3 RCTs, 2 case reports, 1 feasibility study and 2 RCT Protocol. 

Most interventions focused on exercise-based approaches aimed at enhancing postural alignment, mobility, and pain management. Studies evaluating pilates, yoga, postural re-education, and combined corrective exercise programs reported notable improvements in balance, functional capacity, and flexibility. Overall, improvements in pain, trunk mobility, and postural control were frequently reported. However, methodological heterogeneity limited comparison across studies.

Conclusion

Most of the available studies in literature discuss pain but do not focus on LBP specifically. The results of this scoping review suggest that LBP in PwPD is often underestimated in rehabilitation, with poorly understood neurophysiology and physiotherapy approaches remain unclear and inconsistent. 

Furthermore, the results of this scoping review should be interpreted with caution due to the high heterogeneity of intervention, study designs, and outcome measures made direct comparison challenging. This review highlights the need for more knowledge of LBP neurophysiopathology in PwPD and standardized methodologies to better assess and compare the effectiveness of physiotherapy interventions.

REFERENCES

Etchepare F, Rozenberg S, Mirault T, et al. Back problems in Parkinson’s disease: an underestimated problem. Joint Bone Spine. 2006;73(3):298-302. https://doi.org/10.1016/j.jbspin.2005.05.006 

Duncan RP, Van Dillen LR, Garbutt JM, Earhart GM, Perlmutter JS. Low Back Pain–Related Disability in Parkinson Disease: Impact on Functional Mobility, Physical Activity, and Quality of Life. Phys Ther. 2019;99(10):1346-1353. https://doi.org/10.1093/ptj/pzz094 

Silveira Barezani AL, de Figueiredo Feital AMB, Gonçalves BM, Christo PP, Scalzo PL. Low back pain in Parkinson’s disease: A cross-sectional study of its prevalence, and implications on functional capacity and quality of life. Clin Neurol Neurosurg. 2020;194:105787. https://doi.org/10.1016/j.clineuro.2020.105787 

Viseux FJF, Delval A, Simoneau M, Defebvre L. Pain and Parkinson’s disease: Current mechanism and management updates. Eur J Pain. 2023;27(5):553-567. https://doi.org/10.1002/ejp.2096 

Watanabe K, Hirano T, Katsumi K, et al. Characteristics and exacerbating factors of chronic low back pain in Parkinson’s disease. Int Orthop. 2015;39(12):2433-2438. https://doi.org/10.1007/s00264-015-3011-4

HANDWRITING DIFFICULTIES IN PARKINSON’S DISEASE: TECHNOLOGICAL ASSESSMENT AND RESTING-STATE FMRI CORRELATES

Autori

Gardoni Andrea (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Elisabetta Sarasso (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy and Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, University of Genoa, Genoa, Italy)

Lucia Zenere (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy). Roberta Balestrino (Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Marco Forghieri (Vita-Salute San Raffaele University, Milan, Italy). Elisa Sibilla (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Elisa Canu (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy). Andrea Grassi (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Silvia Basaia (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Veronica Castelnovo (Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy). Massimo Malcangi (Neurology Unit and Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy)

Maria Antonietta Volontè (Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy). Davide Corbetta (Department of Rehabilitation and Functional Recovery, IRCCS Ospedale San Raffaele, Milan, Italy)

Massimo Filippi (Neuroimaging Research Unit, Division of Neuroscience, Neurology Unit, Neurorehabilitation Unit, Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy and Neurotech Hub, Milan Italy)

Federica Agosta (Neuroimaging Research Unit, Division of Neuroscience, and Neurology Unit IRCCS San Raffaele Scientific Institute, Milan, Italy and Neurotech Hub, Vita-Salute San Raffaele University, Milan, Italy)

Background and aims

Handwriting is a complex activity requiring cognitive and motor abilities, often impaired in people with Parkinson’s Disease (pwPD). Proper handwriting assessment is essential to develop and evaluate the effect of rehabilitation protocols [1]. The aims of the study were to assess handwriting alterations in pwPD compared to healthy controls (HC) and to identify the functional neural correlates of handwriting changes using resting-state functional connectivity (RS-FC) analysis.

Methods

Forty pwPD and 30 age- and sex-matched HC underwent handwriting and hand dexterity assessments, neuropsychological evaluation, and RS-functional MRI (fMRI). A tablet-based handwriting assessment included four tasks: Systematic Screening for Handwriting Difficulties-SOS test (copying a text), funnel test (coloring a shape), closed loop task (drawing specific symbols), and repetitive cursive loop task (writing repeated symbols). SOS test was executed also on paper. RS-fMRI analysis used MELODIC to identify RS-FC differences, and correlations with clinical variables significantly differing between groups were assessed.

Results

Compared to HC, pwPD showed smaller word size, slower drawing speed, and poorer performance in the handwriting tasks on tablet. SOS test on paper confirmed slower writing speed, smaller size, and lower writing quality in pwPD. RS-FC analysis revealed decreased connectivity in the basal ganglia, cerebellum, ventral default mode, and visual networks, alongside increased RS-FC in the salience and executive control networks. Smaller writing amplitude and poorer handwriting quality were associated with altered RS-FC in motor and cognitive networks.

Conclusion

REFERENCES

[1] Gardoni A, Sarasso E, Basaia S, Corbetta D, Zenere L, Grassi A, Canu E, Castelnovo V, Sibilla E, Malcangi M, Balestrino R, Emedoli D, Volontè MA, Filippi M, Agosta F. Handwriting, touchscreen dexterity and bradykinesia measures in Parkinson’s disease: a feature selection study. J Neurol. 2025 May 11;272(6):389. doi: 10.1007/s00415-025-13121-0. PMID: 40349278.

BUSINESS MODELS IN PHYSIOTHERAPY: A FRAMEWORK TO INTERPRET THE PROFESSION’S TRAJECTORIES IN ITALY

Autori

Cordani Claudio [Department of Biomedical, Surgical and Dental Sciences – University of Milan and IRCCS Galeazzi Sant’Ambrogio Hospital, Milan, Italy]

Pollet Joel [Department of Clinical and Experimental Sciences – University of Brescia and IRCCS Fondazione Don Carlo Gnocchi, Brescia, Italy]

Baseotto Chiara [Ospedale di Vittorio Veneto – ULSS 2 Marca Trevigiana, Vittorio Veneto (TV), Italy]

Altavilla Sabrina [Health Professions Directorate – ASL CN2, Verduno (CN), Italy]

Picardi Salvatore [AORN-Ospedali dei Colli, Naples, Italy]

Baroni Andrea [Department of Neuroscience and Rehabilitation – Ferrara University Hospital, Ferrara, Italy]

Caselli Serena [Azienda Ospedaliero-Universitaria di Modena, Modena, Italy]

Brindisino Fabrizio [Department of Medicine and Health Science “Vincenzo Tiberio” – University of Molise, Campobasso, Italy]; Contino Domenico [Azienda Sanitaria Provinciale di Enna, Enna, Italy]

Del Vecchio Mario, Rappini Valeria, Giacomelli Giorgio [Government, Health and Not for Profit (GHNP) – SDA Bocconi School of Management, Milan, Italy]

Staltari Maria Grazia, Simonelli Marta [Central Committee of the Orders of Physiotherapists National Federation, Rome, Italy]

Background and aims

Physiotherapy in Italy is delivered through a wide range of organizational models across both public and private sectors. In the National Health Service, services are provided by local health authorities and hospitals. In contrast, private practices vary significantly, from solo practitioners to complex multidisciplinary clinics. A major challenge is the lack of a shared, structured understanding of these models among institutional stakeholders, which hinders strategic planning and policy development. This study aims to create a comprehensive framework to identify, classify, and map the main physiotherapy business models. The objective is to support the national federation and regional professional boards in developing evidence-based strategies for professional growth, service integration, and market positioning.

Methods

An inductive qualitative approach was used to identify key variables and distinguish patterns within and across practice types. A Delphi process was conducted over six iterative rounds with a panel of 10 experts and two external facilitators. The panel reached consensus on the most relevant factors shaping the value proposition of physiotherapy settings, resulting in a refined list of classification variables. Four business model types emerged: 1) traditional physiotherapy practices, 2) physiotherapists’ business associations, 3) rehabilitation-focused polyclinics, and 4) multispecialty outpatient centers. Sixteen case studies were then purposefully selected to validate the models, ensuring geographic representation. The cases were analyzed based on team structure, service scope, patient access, remuneration, funding sources, and degree of multidisciplinary integration. These variables are informing a national data collection initiative involving local Order Presidents, data from the “Sistema Tessera Sanitaria,” and a large-scale survey of registered professionals.

Results

At this stage, no quantitative data are available. The results of the preliminary phases consist of a shared descriptive framework of physiotherapy business models. This has enabled the definition of critical variables to be included in the upcoming nationwide survey. These variables include organizational structure, care delivery models, integration with other professionals, patient pathways, and sustainability mechanisms.

Conclusion

This ongoing study represents the first attempt to conceptualize and comprehensively categorize business models in Italian physiotherapy. The emerging framework will guide a broad mapping process and generate insights into current trends, potential risks, and strategic opportunities for the profession. The involvement of the local boards and the National Federation of the Orders of Physiotherapists is anticipated to ensure representativeness and institutional relevance of the forthcoming initiatives.

REFERENCES

N/A

When musical harmony collides with musculoskeletal disharmony

Autori

Silvia Saraceno (Università degli studi di Messina, Messina, Italy)

Francesco Bonanno (Università degli studi di Messina, Messina, Italy)

Francesca Sposito (Università degli studi di Messina, Messina, Italy)

Antonio Di Dio (Università degli studi di Messina, Messina, Italy)

Filippo Cavallaro (Università degli studi di Messina, Messina, Italy)

Veronica Bruno (Università degli studi di Messina, Messina, Italy)

Background and aims

A study by Cruder and colleagues analysed the prevalence of musculoskeletal disorders (MSDs) in 340 music students from various European institutions. Over 80% of the participants attributed their pain to musical activity. The most affected areas were neck, shoulders and upper limbs. Only 43% performed preparatory exercises before playing, and the management of breaks was often unstructured. The most surprising fact is that, despite their young age (average 22 years), many of these students were already living with chronic pain and functional limitations.

Methods

In the following years, we performed over one hundred postural assessments on people engaged in various non-musical activities. Despite the differences in contexts and activities, the problems encountered have many similarities with those highlighted in the study on musicians: cervical stiffness, scapular pain, low back pain and diffuse postural alterations. In 99% of cases, the triggering noxa is not an acute trauma, but the accumulation over time of micro-stress related to muscle weakness and lack of conscious movement. Even today, treatment is only sought when the pain is already chronic and often disabling.

Results

The role of the physiotherapist is not just to “cure pain”, but to help people prevent it. And this applies to everyone, regardless of their activity. Health also depends on conscious movement and good postural education. Preventive physiotherapy is, today more than ever, an essential public health tool. We have proposed a sheet of useful activities in order to make movement and posture conscious.

Conclusion

This comparison shows how prevention in physiotherapy should be considered a priority, not an option. An adequate functional assessment, accompanied by individualised movement education programmes, can significantly reduce the incidence of MSDs and improve quality of life, regardless of age or type of activity.

REFERENCES

Cruder, C., Barbero, M., Soldini, E. et al. Patterns of pain location in music students: a cluster analysis. BMC Musculoskelet Disord 22, 184 (2021). Kok LM et al. – the occurence of musculoskeletal complains among professional musicians: a sistematic review – int. arch. occup. environ health 2016

Prevalence of urinary incontinence in patients with chronic cough: a systematic review

Autori

Scotti Ludovica [University of Udine, Udine, Italy]

Salvitti Simone [Azienda Sanitaria Universitaria Friuli Centrale, University of Udine, Udine, Italy]

Background and aims

Individuals with diseases associated with chronic cough have a higher risk of developing urinary incontinence, due to repeated increasing endoabdominal pressure that is spread over the pelvic floor (1). Studies found in literature examine populations affected by a single disease and do not extend the analysis to the main problem, that is urinary incontinence. The aim of the study is to determine the prevalence of urinary incontinence in patients with diseases associated with chronic cough and to compare it with the prevalence of urinary incontinence in healthy populations.

Methods

The systematic review followed the PRISMA 2020 guidelines, with study selection based on a predefined protocol. The search was conducted through Medline, Embase, Cochrane, OvID, Scopus, ProQuest, PEDro and EBSCO. The study selection process, done by two blinded revisors utilizing a Microsoft Excel spreadsheet, included only prevalence studies that met the prespecified criteria. Data from selected studies were extracted and synthesized. The evidence was then assessed using the GRADE method and quality of reporting was assessed using the STROBE checklist.

Results

A total of 1585 articles were identified through database searches, with three added via reference screening. After duplicate removal and screening, 23 observational studies (cross-sectional or prospective) published between 2000 and 2024 were included. These studies investigated urinary incontinence (UI) prevalence in patients with chronic respiratory diseases, with considerable variability in demographics and disease characteristics. UI prevalence in patients with chronic cough ranged from 2.2% to 45% in pediatric patients, 30.4% to 74% in adult women, and 2.4% to 39% in adult men. 11 studies included only females, 3 only males and 9 mixed-gender populations. Most had small sample sizes (<250), while 3 were nationwide. Inclusion criteria were broad, particularly in cystic fibrosis, while exclusion criteria were more consistent. UI was primarly assessed via ICIQ-SF questionnaires. Risk factors included overweight (2) in chronic cough and underweight in cystic fibrosis. Lower FEV1% predicted correlated with increased UI in some cases, The quality of evidence was low, while reporting quality was acceptable.

Conclusion

This review met its objective of investigating the prevalence of urinary incontinence (UI) in patients with chronic cough-related diseases. Results show significantly higher UI rates in females, often double those in healthy individuals. Prevalence estimates for pediatric and male populations remain unclear, requiring further research. The underestimated nature of UI calls for enhanced clinical guidelines, patient education, and clinician engagement, as stigma and limited awareness may prevent proper diagnosis and treatment (3).

REFERENCES

(1) Cobb WS, Burns JM, Kercher KW, Matthews BD, James Norton H, Todd Heniford B. Normal Intraabdominal Pressure in Healthy Adults. J Surg Res. dicembre 2005;129(2):231–5.

(2) Shang X, Fu Y, Jin X, Wang C, Wang P, Guo P, et al. Association of overweight, obesity and risk of urinary incontinence in middle-aged and older women: a meta epidemiology study. Front Endocrinol. 10 ottobre 2023;14:1220551.

(3) Haukeland-Parker S, Frisk B, Spruit MA, Stafne SN, Johannessen HH. Treatment of urinary incontinence in women with chronic obstructive pulmonary disease—a randomised controlled study. Trials. dicembre 2021;22(1):900.

Implementation of a Lymphedema Counseling Service in Reggio Emilia: An Integrated Organizational Model within the Territorial Lymphedema Network

Autori

Dimatteo Mariangela (FT) – Medicina fisica e riabilitazione ASMN, AUSL-IRCCS di Reggio Emilia – Italia; Studente del master in Riabilitazione in linfologia clinica Universitaria La Sapienza di Roma

Alice Pecorari (FT) Servizio RRF di Correggio, AUSL-IRCCS di Reggio Emilia, Italia; Studente del master in Riabilitazione in linfologia clinica Universitaria La Sapienza di Roma

Bassoli Agnese (FT) Servizio NPIA, AUSL-IRCCS di Reggio Emilia, Italia; Laureanda magistrale in scienze riabilitative delle professioni sanitarie presso Univr – Università degli studi di Verona

Piccinelli Barbara (Medico Fisiatra) Medicina fisica e riabilitazione ASMN, AUSL-IRCCS di Reggio Emilia, Italia

Manfredi Nicoletta (FT) Medicina fisica e riabilitazione ASMN, AUSL-IRCCS di Reggio Emilia, Italia

Giberti Tiziana (FT) Servizio RRF CNM, AUSL-IRCCS di Reggio Emilia, Italia

Isabella Campanini, PhD LAM (Dip. Neuromotorio Riabilitativo) AUSL-IRCCS di Reggio Emilia

Rancati Jacopo Matteo (Dirigente Professioni Sanitarie della Riabilitazione) Direzione Assistenziale, AUSL-IRCCS di Reggio Emilia, Italia

Background and aims

Lymphedema is a chronic, progressive, and disabling condition caused by impaired lymphatic transport, often resulting in substantial functional limitations and reduced autonomy.
As with many chronic conditions, its management entails considerable healthcare expenditures. Current literature advocates for organizational models that enhance patient participation in the continuum of care.
Institutional monitoring data indicate that, following completion of the physiotherapy cycle, patients frequently initiate informal contact with physiotherapists—typically in response to symptom recurrence or to request advice on newly arising concerns.

Methods

Within the existing territorial lymphedema rehabilitation network, a structured rehabilitative counseling service has been designed. The service is accessible via a secure digital platform, with the objective of formalizing, tracking, and expanding access to such informal consultations.
This direct-access model aims to offer timely and appropriate responses to low-complexity rehabilitation needs. Each patient may access the service for up to two consultations—either in person or via telemedicine—allowing the physiotherapist to assess the case and propose suitable interventions. In cases requiring more comprehensive care, the physiotherapist may directly initiate referral for physiatric evaluation.

Results

The launch of the rehabilitative counseling service is scheduled for Autumn 2025, with an initial pilot phase involving two healthcare districts.
Service requests will be managed through a secure online form, serving as the user interface for access. The structure of this form will be informed by observational data collected from patients who currently engage the service informally.
Preliminary data suggest that the most frequently reported needs include: counseling on compression garments and bandaging techniques, verification of appropriate use of assistive devices, symptom self-management support, and lifestyle education.
During the first year of implementation, the service is expected to handle approximately 100 requests, with over 50% of cases likely to be managed autonomously by physiotherapists, without requiring referral for physiatric consultation.
In the long term, this model aims to reduce both the number of physiatric referrals and physiotherapy sessions for this patient population by approximately 10%.
Additional indicators will be monitored to evaluate the model’s effectiveness, including: case typology, nature of the interventions provided, response times, and user satisfaction, leveraging data generated through the digital request platform.

Conclusion

The activation of a lymphedema counselling service represents an innovative model of care, based on therapeutic education, self-management and proximity of the intervention, accordig with DM 77/2022. The project enhances the physiotherapist as a territorial reference point within the lymphological network, helping to reduce inappropriate access to physiatric visits and repeated treatments.

REFERENCES

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• Hernandez Silva E, Lawler S, Langbecker D. The effectiveness of mHealth for self-management in improving pain, psychological distress, fatigue, and sleep in cancer survivors: a systematic review. Journal of Cancer Survivorship. 2019; 13: 97-107.