Telerehabilitation for Parkinson's Disease
Telerehabilitation for Parkinson's Disease
Our primary objective in this 10-week pilot study is to demonstrate the feasibility of using
 videoconferencing technology to provide Parkinson's Disease (PD) patients, alongside their
 supervising care partners, specialized physical and occupational therapy (PT/OT) focused on
 neurorehabilitation that ultimately aims to reduce fall risk. This therapy is similar to what
 a PD patient could receive in-person with neurologic-certified physical therapists and
 occupational therapists with significant experience working with PD patients and addressing
 their needs, but it is delivered through a virtual platform. Feasibility is defined by
 measures of adherence, retention, and safety.

 The specialized PT and OT measurement tools and strategies used in this study are in-line
 with the most current formal evidence-based guidelines/recommendations available for therapy
 in PD: European Physiotherapy Guideline for Parkinson's Disease, Parkinson Evidence Database
 to Guide Effectiveness (PD-EDGE) Task Force and Guidelines for Occupational Therapy in
 Parkinson's Disease Rehabilitation.

 The study duration is approximately 10 weeks of the primary telerehabilitation intervention
 and a 2 follow-up phone calls at the 3- and 6-month timepoints. There will be one baseline
 in-person evaluation and one final in-person evaluation following the completion of all
 televists. The enrollment target is up to 15-20 patient and care partner (P+CP) pairs,
 meaning 30-40 subjects total. There are no controls for this study.
Gait dysfunction, postural instability, and freezing-of-gait (FOG) ultimately develop in
 about 80% of PD patients, which lead to falls and advancing disability. This is significant
 because the consequences of falls are far-reaching: accelerating immobility due to heightened
 fear-of-falling, reducing quality of life and independence, and increasing healthcare
 utilization and costs. Thus, there is an urgent need to expand evidence- based outpatient
 neurologic-PT/OT services to community-dwelling PD patients to reduce fall risk.

 This research proposal will address this unmet need by determining whether
 tele-neurorehabilitation is a care model that can be executed safety for PD patients to
 provide these services from well-trained therapists who are not easily accessible otherwise.
 This feasibility data is critical in the development of a novel tele-neurorehabilitation
 protocol and randomized-controlled efficacy trial thereafter.

 The impact of the intended research is to demonstrate the feasibility and preliminary
 efficacy of this novel teleconferencing-based delivery of gait and balance
 exercises/strategies with guided instruction much like one would receive in-person but in the
 comfort of one's own home. By demonstrating the feasibility and preliminary efficacy of this
 pilot program, subsequent long-term goals are to apply for larger sources of funding to
 sustain the program. By leveraging the data gained from these studies it is anticipated the
 practice of telerehabilitation will be expanded and improved; and ultimately its efficacy to
 health care policy providers and insurers for potential reimbursement will be demonstrated.

 The researchers intend to enroll 15-20 individuals with mild-moderate PD into our proposed
 novel telerehabilitation program, where patients will receive tele-PT/OT home visits and
 home-safety surveillance with neurologic-specialized therapists who are experienced with the
 core problem areas seen in PD patients. The intended clinical impact is to improve
 gait/balance function and postural stability, and thus reduce falls in patients with PD. With
 the remote telecommunications intervention, we aim to enable the additional clinical impact
 of expanding access to therapy for people with PD that otherwise would have significant
 difficulty obtaining this type of multiple-visit, individually-tailored, and specialized
 therapy care due to travel burden and cost.

 References:

 1. Marras C, Beck JC, Bower JH, et al. Prevalence of Parkinson's disease across North
 America. NPJ Parkinsons Dis. 2018 Jul 10;4:21.

 2. Macht M, Kaussner Y, Moeller JC, et al. Predictors of freezing in Parkinson's disease: a
 survey of 6,620 patients. Mov Disord. 2007; 22:953-956.

 3. Hely MA, Morris JG, Reid WG, et al. Sydney Multicenter Study of Parkinson's disease:
 non-L-dopa-responsive problems dominate at 15 years. Mov Disord. 2005; 20:190-199.

 4. Poewe W. The natural history of Parkinson's disease. J Neurol. 2006 Dec;253 Suppl
 7:VII2-6.

 5. Low V, Ben-Shlomo Y, Coward E, et al. Measuring the burden and mortality of
 hospitalization in Parkinson's disease: A cross-sectional analysis of the English
 Hospital Episodes Statistics database 2009-2013. Parkinsonism Relat Disord. 2015
 May;21(5):449-54.

 6. Wielinski Cl, Erickson-Davis C, Wichmann R, et al. Falls and injuries resulting from
 falls among patients with Parkinson's disease and other Parkinsonian syndromes. Mov
 Disord. 2005;20:410-415.

 7. Pressley JC, Louis ED, Tang MX, et al. The impact of comorbid disease and injuries on
 resource use and expenditures in parkinsonism. Neurology. 2003 Jan 14;60(1):87-93.
Subject Inclusion Criteria:

 1. Subject's age is greater than or equal to 18.

 2. Subject has a diagnosis of Idiopathic Parkinson's Disease according to established
 criteria and this has been confirmed by a Movement Disorders Neurologist.

 3. Subject's Movement Disorders Neurologist believes he/she would benefit from
 specialized physical and occupational therapy to reduce fall risk.

 4. Subject's Idiopathic Parkinson's Disease is Hoehn and Yahr stage 2 or 3 in the
 "OFF"-medication state (stage 2 defined by bilateral or midline symptoms with less
 than or equal to 2 steps back on the pull test with self-recovery; stage 3 is defined
 by more than 2 steps back on the pull test with or without self-recovery, or no steps
 back and requiring assistance to recover).

 5. Subject demonstrates the ability to utilize the virtual platform at their initial
 in-person evaluation.

 6. Subject has been on a stable medication regimen for the treatment of Idiopathic
 Parkinson's Disease for the month preceding the baseline in-person visit, and has the
 ability to maintain stable dosing for the duration of the 10-week primary
 intervention.

 7. Subject has home Wi-Fi access for the tele-neurorehabilitation home visits and a
 personal tablet with Wi-Fi connectivity.

 Care Partner Inclusion Criteria:

 1. Care partner's age is greater than or equal to 18.

 2. Care partner has been the primary caregiver for >6 months and will remain so for at
 least 10 weeks to the study subject.

 3. Care partner has the ability and desire to participate in all of the study visits with
 the study subject, including the tele-neurorehabilitation home visits.

 4. Care partner has the ability and desire to provide stand-by assistance, but in the
 setting of a gait belt, to the study subject during tele-neurorehabilitation home
 visits.

 Subject Exclusion Criteria:

 1. Subject is non-English speaking.

 2. Subject has only a provisional diagnosis of Idiopathic Parkinson's Disease or atypical
 features suggestive of an alternative diagnosis.

 3. Subject has and additional significant neurologic diagnosis that may render him/her
 with neurologic deficits that may affect gait and balance.

 4. Subject has another destabilizing chronic medical condition which may warrant frequent
 hospitalization or render the patient unable to participate in physical activity.

 5. Subject requires more than just stand-by assistance for gait and balance.

 6. Subject is reliant on mobility devices to walk (walkers, cane, walking sticks,
 motorized scooter, etc).

 7. Subject is receiving physical therapy elsewhere during the month preceding the study
 and during the duration of the study.

 8. Subject has no care partner available to participate in all of the study visits.

 9. Subject is unable to follow direction or consent to research.

 10. Subject is unable to commit to the study-related activities and/or schedule of events.

 Care Partner Exclusion Criteria:

 1. Care partner is non-English speaking.

 2. Care partner is unable to follow direction or consent to research.

 3. Care partner is unable to commit to the study-related activities and/or schedule of
 events.