Posted October 17, 2023

Miriam Rafferty, Ph.D., Shirley Ryan AbilityLab

Parkinson’s disease (PD) is a neurodegenerative disease that affects the function of the body’s nervous system. According to the National Institutes of Health (NIH) Parkinson’s Disease Fact Sheet, as the disease progresses, dopamine-producing neurons die off, preventing nerves from properly communicating with muscles and organs, and eventually resulting in loss of common motor abilities [NIH 2022]. An estimated 1.04 million Americans in the United States were diagnosed with PD in 2017, the scientific journal npj Parkinson’s Disease stated [Yang 2020]. Additionally, well over 110,000 Veterans sought PD treatment from the Department of Veterans Affairs (VA), underscoring its relevance in the military. These statistics are likely to double over the next 10 years due to the increased aging population. For individuals who suffer from PD, research suggests that regular physical exercise is associated with slower declines in mobility and quality of life [Rafferty et al 2017]. However, by the time patients are diagnosed with PD, many have already reduced their exercise and can have difficulty with walking or balance.

Through a fiscal year 2020 (FY20) Early-Investigator Research Award, the Neurotoxin Exposure Treatment Parkinson’s (NETP) program provided funding to Dr. Miriam Rafferty, whose aim is to bridge the gap between digital health research and behavioral interventions in real-world physical therapy (PT) settings to improve exercise maintenance and monitoring. (Congress transitioned the NETP to the Parkinson’s Research Program [PRP] in FY22, and the PRP now manages this award.) Dr. Rafferty and her team hypothesized that use of advanced digital health technology with exercise-related behavioral interventions would increase regular exercise participation and improve physical function and fitness in people with early-stage PD. The researchers designed the project with the patient in mind, developing a “bring your own device” strategy. Using their own devices was a strategy that could be implemented by physical therapists without extra costly software packages, and study participants could become more comfortable using their own personal technology at home through their physical therapy.

During the observational cohort study, 32 people with Parkinson’s (PwP) were identified and enrolled for participation. Prior to implementation, Dr. Rafferty and her team assessed barriers and facilitators of digital health technology use from the perspectives of PwP, physical therapists, and advanced technology stakeholders. PwP reported that fitness tracking would be a motivator, and physical therapists thought it would be feasible to help them monitor their patient’s exercise. After six months, medical records and phone surveys were used to assess how digital health technology and behavioral interventions were adopted by individuals with mild to moderate PD and their physical therapists. The project also looked at whether the use of the technology paired with behavioral intervention was successful in changing the fitness and function in patients. Physical therapists used behavioral interventions and data from activity-tracking devices such as watches, pedometers, and smartphone applications to help set personalized goals for patients to increase daily steps and overall physical activity. Rafferty and her team have continued collecting and analyzing the data, and they are performing exit interviews with the physical therapists and PwP to identify what helped facilitate physical activity and exercise, and what factors continued to act as a barrier despite digital health technology use.

Preliminary results suggest that there were two major technology user groups. Some PwP who had high levels of comfort with the technology could be independent after their physical therapist helped them set goals, using their devices. Another group of users required technical assistance beyond what is traditionally provided by physical therapists to successfully engage with their devices, such as follow-up phone calls for technical assistance from a trained physical therapist. The enrolled subjects were relatively highly active individuals, so self-reported moderate-vigorous exercise did not increase, but there was a trend toward increased six-minute walk distance (a physical therapy measure of walking endurance). Exit interviews suggest that most participants appreciated the use of digital health technology and guidance from their physical therapists. They reported benefiting from recommendations on individually tailored, comprehensive exercise programs that included agility, strengthening, stretching, and education on exercise intensity. Analyses will be finalized in 2023.

Individuals who had difficulty adopting digital health technology reported wanting more educational resources such as videos, handouts, individual instruction, or small-group lessons on how to use their devices. However, few individuals initiated follow-ups with their physical therapist when they experienced technology or exercise challenges. Physical therapists may need to proactively schedule follow-up sessions for PwP who want to improve their exercise routine but report lower exercise or technology confidence. The resources the participating physical therapist shared with patients participating in the study are available on Dr. Rafferty’s website (click here).

Dr. Rafferty’s recent research confirms her previous work that early-stage PD patients report benefits of regular exercise. Regular exercise may be associated with slowing the decline of mobility and progression of symptoms, increasing their quality of life. A 2021 publication in the scientific journal Current Neurology and Neuroscience Reports described the framework for delivering this proactive rehabilitation care that provides patients with the best chance of success early after diagnosis [Rafferty 2021]. The proposed approach, using tailored interventions and advanced digital health, could have a direct impact on patients with early-stage PD by helping slow down symptom progression.

Sources:

Parkinson’s Disease Health Topic Fact Sheet. Reviewed 2022. National Institutes of Health. https://www.niehs.nih.gov/health/topics/conditions/parkinson/index.cfm

Yang W, Hamilton JL, Kopil C, et al. 2020. Current and projected future economic burden of Parkinson’s disease in the U.S. npj Parkinson's Disease 6(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347582/#:~:text=We%20estimated%20that%201.04%20million,443%2C000%20females

Rafferty M, Nettnin E, Goldman J, and MacDonald J. 2021. Frameworks for Parkinson’s disease rehabilitation addressing when, what, and how. Current Neurology and Neuroscience Reports 21(3):1-10. https://doi.org/10.1007/s11910-021-01096-0

Links:

Technical and Public Abstracts: Accelerating Physical Therapy Exercise Monitoring: Facilitators, Fidelity, and Fitness

Project website at Shirley Ryan AbilityLab includes the resources we shared with our participants through the research study: https://www.sralab.org/research/labs/kteam/projects/digital-health-technology-physical-therapy

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