Parkinson disease (PD) is one of the most disabling chronic health conditions that affect adults.1 Advances in the medical and surgical management of PD increased lifespans but have not effectively altered the decline in physical function and quality of life that accompanies the disease.1 Physical therapy is an important component in the management of gait and balance impairments in people with PD; exercise might even have a disease-modifying impact.2,3
Multiple forms of exercise have been shown to ameliorate PD symptoms.2,4 Functional and task-specific training targets everyday mobility to facilitate motor learning and transfer into real-life activities. A complete understanding of the mechanisms that underlie the benefits of exercise in PD is lacking; however, the therapeutic effects are becoming clear. Patients who exercise and are physically active have better outcomes than those who do not.5 However, patients with PD have specific barriers to exercising, including disease-specific balance and gait impairments,6 cognitive impairments, increased risk of falls, apathy, and depression that can contribute to sedentary behavior. Lack of time, travel distances, uneven distribution of rehabilitation services, and fear of falling may also deter participation in traditional interventions.7 The current coronavirus pandemic (COVID-19) further increased the need for new approaches to promote exercise in patients with PD. The lack of physical activities may lead to worsening of motor and nonmotor symptoms.4,8
Telerehabilitation enables patients to access rehabilitation services in their homes.7 Telecommunication technology allows for supervision of a rehabilitation program remotely through audio and visual real-time communication and is a viable solution to address several of the barriers that discourage exercise, while also maintaining social distancing.8 Exercising in the home could also boost adherence and adaptation to real-life environment, improve self-reliability, and enhance self-empowerment.8
Three major types of telerehabilitation tools exist: virtual reality (VR) platforms, exergaming, and immersive reality. VR platforms provide game-like exercises in virtual environments to elicit greater improvements in gait, balance, activities of daily living, and quality of life. A recent RCT reported improvements in motor and cognitive function with a significant reduction in fall rates in patients with PD after a 6-wk intervention using a unique treadmill-VR system in a clinical setting.9 To address the needs of telerehabilitation, such systems can be adapted for home use. Indeed, VR or exergaming telerehabilitation programs are feasible and effective in several neurologic conditions,10,11 including PD.12,13 However, most previous studies involved only short-duration trials with individualized “one-on-one” training. Such an approach may be effective but it is time-consuming for the trainer. The aim was to explore the feasibility of using VR-telerehabilitation for simultaneous training of two participants over a year. It was hypothesized that such rehabilitation delivery could potentially be less time-consuming for therapists while increasing user socialization and maintaining consistent physical activity and well-being. This case report describes the feasibility and potential of using a VR-telerehabilitation program for simultaneously training two patients with PD in their home.
The system consists of a treadmill, a TV screen, a depth camera (Microsoft Kinect) + Microsoft HD camera, and a personal computer installed with the VR simulation. The cameras track the movement of the participant’s feet during treadmill walking. The images are inserted into the VR simulation and projected to the patient on the screen, providing real-time feedback on performance (Fig. 1A). The virtual environment consists of different obstacle-lined pathways requiring the user to modulate his or her gait to negotiate the obstacles projected on the screen (e.g., take a longer step or increase foot clearance). The training requires motor control, sensory integration, and cognitive function, engaging several domains such as executive function (e.g., decision making, planning), attention (e.g., ignoring distractors), working memory (e.g., navigation), and visual processing (e.g., timing of motor planned action).9
The VR system was previously used with patients with PD.9 Therefore, for this feasibility pilot, two patients with PD were recruited from the movement disorders unit at the Tel Aviv Medical Center. Patients were recruited as they were male and female, were willing to have the system installed in their homes, and had similar disease duration and symptom presentation. Participant A is a 46-yr-old male patient with PD (disease duration, 17 yrs; Movement Disorder Society-Unified Parkinson’s Disease Rating Scale [MDS-UPDRS] motor, 29; Hoehn and Yahr scale, 3). Participant B is a 67-yr-old female patient (disease duration, 15 yrs; MDS-UPDRS motor, 30; Hoehn and Yahr scale, 3). Both patients received conventional physical therapy (weekly one-on-one session) before starting the telerehabilitation. Both were on levodopa treatment, with a levodopa equivalent daily dose of 815 and 1000 mg for participants A and B, respectively. They were ambulatory but had difficulties in outdoor walking and complex environments. The study was approved by the ethical committee of the Tel Aviv Medical Center according to the guidelines of the Helsinki declaration and both participants provided informed written consent before participation. This study conforms to all CARE guidelines and reports the required information accordingly (see Supplemental Checklist, Supplemental Digital Content 1, https://links.lww.com/PHM/B265). To accommodate the home training, additional video cameras were installed to provide a full-size body presentation in the frontal and lateral view. Remote monitoring software (Google Chrome remote desktop tool) and Skype were also installed to enable visual and auditory communication during training. This configuration allowed the trainer (i.e., a physical therapist) to monitor the participant’s movement, provide feedback in real-time, and manage all parameters of the training simulation remotely and enabled the participants to converse with the trainer. Both participants used a safety button that stopped the treadmill upon stumbling for protection and to prevent falls and had the option to use a harness, attached to the ceiling for safety. The trainer station included a personal computer with three monitors (Fig. 1B) to enable the monitoring of both participants simultaneously and a microphone and earphones for communication. The system is not commercially available and is still investigational, but it can be speculated that such a system will cost ~$2000 (including the treadmill).
The training protocol consisted of weekly sessions. Each session was divided into three walking bouts of 5–15 mins, with 5–10-min rest breaks between each bout. Initial treadmill speed was set at the participant’s’ comfortable gait speed in the first training session. Training progression consisted of increasing gait speed and walking duration (the motor component) by 10% each week and increasing pathway complexity every 2 wks by increasing the number and size of the obstacles and reducing the timing of obstacle appearance. In addition, the level and number of attention distractors and memory challenges (the cognitive component) were increased weekly. The system provides feedback on performance in the form of success in obstacle negotiation as well as knowledge of results (number of obstacles passed and distance walked). The therapist’s feedback was directed toward performance quality and movement strategies. Training settings were controlled remotely to change the level of challenge.
Feasibility and adherence to the training were assessed based on the number of sessions participated and self-report of the patients and therapist. The effects of training on mobility were assessed as the change in preferred gait speed (measured on the treadmill) and walking endurance (duration of walking time) between the first and last sessions. The Activities-Specific Balance Confidence Scale evaluated the patient’s perceived level of balance confidence in activities of daily living (score range, 0–100, with higher scores indicating better performance).14 The MDS-UPDRS and Hoehn and Yahr scale were assessed by a movement disorders specialist before and after the training (while on medication, in the clinic) to evaluate disease symptoms.
Both participants completed 12 mos of weekly training (May 2019–2020), finishing 71% and 78% of all training sessions. Participants reported that training from home enabled them to sustain weekly training with more ease. They further denoted that the monitored trainer session increased their commitment to the training, stating that if the sessions were self-administered, their participation would likely be lower.
Gait speed increased on average by 30% (participant A: from 2.8 km/h to 3.8 km/h; participant B: from 3 km/h to 3.8 km/h) (Fig. 2). Training endurance increased for both patients by 200% from walking 15 mins in the first session to 45 mins at the end of the year. Both participants showed improved confidence in mobility (measured by the Activities-Specific Balance Confidence Scale) with an increase of 45% and 27% for participants A and B, respectively (participant A, from 45% to 67%; participant B, from 55% to 70%). Both participants also reported that they were able to walk outdoors for longer distances without assistance. No falls were sustained during training. Assessment of disease symptoms revealed only minor progression over a full year (change in MDS-UPDRS motor: participant A, 3 points with no change in levodopa equivalent daily dose; participant B, 2 points with only a small increase in levodopa equivalent daily dose of 125 mg). Both patients had no deterioration in the Hoehn and Yahr scale.
Participants were aware of each other but were not able to communicate directly, only through the trainer. They noted that the interactive training session increased their motivation to work harder. From the trainer’s perspective, monitoring two participants simultaneously was challenging but doable. The trainer noted the advantage of increasing the patient’s motivation by tapping into their competitiveness and the advantage in time efficiency (able to attend to two patients at the same time).
During the COVID-19 pandemic, participant B was confined to her home because of isolation after exposure. The patient had no symptoms and was able to continue training as usual with no inconvenience.
DISCUSSION AND CONCLUSIONS
To the authors’ knowledge, this is the first case report of a simultaneous multiparticipant VR telerehabilitation approach for patients with PD. Weekly sessions were provided over 1 yr to two patients with PD in their home setting. The initial findings demonstrate that this approach is feasible, promotes long-term adherence, and has some beneficial effects on mobility and confidence. These findings are similar to those presented in single-participant telerehabilitation balance training,6,10 highlighting the potential of such an approach to conserve therapist time. Two patients with advanced PD were specifically included to investigate the feasibility of this approach for a population with impaired mobility who may also have difficulties traveling to the clinic. Both the trainer and participants noted the advantage of telerehabilitation, providing the participants access to a service without leaving their homes. This was especially important during the COVID-19 lockdown period, enabling the participants to continue training as usual. The trainer’s reported, based on his experience, that it is possible to have good communication with the trainees without the necessity of the physical presence, while still providing feedback and motivation to sustain training for an extended duration. The multiparticipant technique proved to be feasible, allowing an individualized treatment approach while also conserving therapist time. It is probable that such sessions can include additional participants. This should be explored in future studies.
Interestingly, the observed increase in gait speed was greater than the minimal clinically important difference (0.25 m/sec),15 reflecting a meaningful motor improvement. This is further highlighted in the minimal increase in disease severity measures, for both patients, which was lower than the expected change over 1 yr in medicated patients.16 Clearly, one cannot draw conclusions from only two participants. Nonetheless, one can speculate that regular mobility training and motor and cognitive engagement helped to maintain function and curb deterioration. It is possible that the VR training induced plastic changes, whether in the form of improved neural activation17 or improved neural efficiency.18 Future studies should explore this further.
In recent years, there is growing adoption of technology into rehabilitation care in the home. This study began before the COVID-19 pandemic, which brought new challenges in rehabilitation and care. Technology has played a key role in adapting to this pandemic. Video conferencing has become the norm, and various technologies have allowed physicians to communicate with isolated individuals in the community. Digital rehabilitation approaches that maintain social distancing and reduce the fear of infection provide an alternative model for delivering rehabilitation services while also targeting some of the known barriers for exercise in PD,19–21 addressing the specific needs of the participant while also providing the social contact patients so desperately need. The use of telerehabilitation will likely remain an important tool for the near future, even once the pandemic has gone. The positive results of this case study demonstrate the potential of such an approach.
The authors would like to thank the participants in this study.
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