976265

research-article2020
CRE0010.1177/0269215520976265Clinical RehabilitationFlynn et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Home-based exercise monitored 1­–12

© The Author(s) 2020
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DOI: 10.1177/0269215520976265
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centre-based exercise in
Parkinson’s disease:
A randomised pilot study

Allyson Flynn1,2 , Elisabeth Preston2, Sarah Dennis1,3,4,

Colleen G Canning1 and Natalie E Allen1

Abstract
Objectives: To investigate the feasibility and acceptability of a home-based exercise program monitored
using telehealth for people with Parkinson’s disease.
Design: Pilot randomised control trial.
Setting: University physiotherapy clinic, participants’ homes.
Participants: Forty people with mild to moderate Parkinson’s disease, mean age 72 (6.9).
Intervention: In Block 1 (5 weeks) all participants completed predominantly centre-based exercise plus
a self-management program. Participants were then randomised to continue the centre-based exercise
(n = 20) or to a home-based program with telehealth (n = 20) for Block 2 (5 weeks). The exercises targeted
balance and gait.
Outcomes: The primary outcomes were the feasibility and acceptability of the intervention. Secondary
outcomes were balance, gait speed and freezing of gait.
Results: Adherence was high in Block 1 (93%), and Block 2 (centre-based group = 93%, home-based
group = 84%). In Block 2, the physiotherapist spent 6.4 hours providing telehealth to the home-based
group (mean 10 (4) minutes per participant) and 32.5 hours delivering the centre-based exercise classes
(98 minutes per participant). Participants reported that exercise was helpful, they could follow the home
program and they would recommend exercising at home or in a group. However, exercising at home

1
 iscipline of Physiotherapy, Sydney School of Health
D Corresponding author:
Sciences, Faculty of Medicine and Health, The University of Allyson Flynn, Discipline of Physiotherapy, Faculty of Health,
Sydney, NSW, Australia Office 11, Clinical Education and Research Centre, University
2
Discipline of Physiotherapy, Faculty of Health, University of of Canberra Hospital, 20 Guraguma Street, Bruce, ACT 2617,
Canberra, Bruce, ACT, Australia Australia.
3
South Western Sydney Local Health District, Liverpool, Email: Allyson.Flynn@canberra.edu.au
NSW, Australia
4
Ingham Institute of Applied Medical Research, Liverpool,
NSW, Australia
2 Clinical Rehabilitation 00(0)

was less satisfying and there was a mixed response to the acceptability of the self-management program.
There was no difference between groups in any of the secondary outcome measures (preferred walking
speed mean difference −0.04 (95% CI: −0.12 to 0.05).
Conclusion: Home-based exercise monitored using telehealth for people with Parkinson’s disease is
feasible and acceptable.

Keywords
Parkinson’s disease, exercise therapy, home-based, physiotherapy, telehealth

Received: 10 August 2020; accepted: 4 November 2020

Introduction which was then progressed to a home-based exer-

Physiotherapist-prescribed home-based exercise
for people with Parkinson’s disease has been shown
to be effective in improving balance-related activi-
ties and gait speed in the short-term, with similar
benefits to centre-based exercise.1 Despite this,
most evidence for exercise has been from trials
conducted at a facility with full physiotherapist
supervision.2 As exercise for people with
Parkinson’s disease needs to be ongoing to main-
tain improvements, there is value in exploring
home-based exercise as a more sustainable model
of exercise provision.3 The advantages of home-
based exercise include convenience, affordability
and accessibility with minimal resources. However,
home-based exercise limits opportunities for feed-
back, monitoring and social interaction; all impor-
tant factors in motivating people with Parkinson’s
disease to continue exercising.4
To address these limitations home-based exer-
cise programs for people with Parkinson’s disease
have explored ways to provide feedback, monitor-
ing and support including using telehealth, where
the provision of health care is provided remotely
using telecommunication tools.5–7 Other trials
involving home-based exercise have incorporated
a component of exercise self-management with the
use of apps,8 and remote coaching.9 However, there
is still little known about the acceptability and fea-
sibility of such approaches.
The aim of this pilot randomised trial was to
determine whether home-based exercise, that fol-
lows an initial centre-based exercise program, was
feasible and acceptable. It involved an initial centre-
based exercise and self-management program,
cise program monitored using telehealth. This model
provided instruction, feedback and social interaction
and gave participants an opportunity to develop
exercise self-management skills to facilitate engage-
ment with the home program, while increasing the
number of people with Parkinson’s disease who
could access the physiotherapy clinic.
Method
This was a randomised controlled feasibility trial.
The study was registered with the Australian New
Zealand Clinical Trials Registry (ACTRN
12617000503325). The study had ethical approval
from the University of Canberra Human Research
Ethics Committee (16-153). The study was con-
ducted between May 2017 and July 2019.
The study was conducted at a university physi-
otherapy clinic and in the participants’ homes, with
all outcome measures completed at the university
clinic. Community dwelling people diagnosed with
idiopathic Parkinson’s disease were invited to par-
ticipate in the study when they presented as new
patients to the University Parkinson’s clinic and
through advertisements at the local Parkinson’s
support groups. To be considered for inclusion vol-
unteers were required to have stable Parkinson’s
medication for at least 2 weeks prior to baseline
measurement. They were excluded if they had sub-
stantial cognitive deficit (Mini-Mental State
Examination: <24)10 or a medical condition which
would interfere with measurement or the interven-
tion. All participants provided written informed
consent prior to taking part in the trial.
Flynn et al. 3
Participants completed a 10-week exercise
intervention divided into two 5-week blocks. In
Block 1 (weeks 1–5), all participants completed
predominantly centre-based exercise in conjunc-
tion with an exercise self-management program at
a university clinic. On completion of Block 1, par-
ticipants were randomised to continue the predom-
inantly centre-based exercise program or to
participate in a home-based exercise program mon-
itored using telehealth during Block 2 (weeks
6–10). The randomisation was computer gener-
ated, using permuted blocks of two, four and six.
Randomisation was performed remotely, and the
results placed into opaque envelopes, thereby con-
cealing the sequence of group allocation from the
researcher recruiting the participants.
The primary outcome was feasibility of recruit-
ment (i.e. uptake), and feasibility and acceptability
of the intervention. Feasibility of recruitment was
determined by examining the number of participants
screened, eligible and enrolled. Feasibility of the
intervention was determined by measuring the time
taken to develop the exercise program, participant
adherence to the exercise program and number of
adverse events. Adherence was determined by
recording the number of exercise sessions attempted.
If a participant completed more than the prescribed
number of sessions then adherence was capped at a
maximum of 100% for all analyses. Acceptability
was examined using a participant questionnaire
about the program, conducted in weeks 5 and 10.
Participants were also interviewed about their expe-
riences of exercise at home and in a centre and this
will be the topic of a separate report.
All measures were completed by two trained
physiotherapists who were blinded to group alloca-
tion. Measurements were conducted during the
participants ‘ON’ medication phase.
Participants’ age, sex and disease severity (Hoehn
and Yahr and Movement Disorders Society Unified
Parkinson’s disease Rating Scale part III), were col-
lected at baseline to describe the participants.
The clinical outcome measures for balance, gait
speed and freezing of gait were conducted at base-
line and in the week following completion of the
10-week intervention. Balance was measured using
the MiniBESTest.11 Gait speed was measured using
the 10 m walk test under four conditions; preferred
speed, dual task manual, dual task cognitive and fast
speed. Participants walked along a 14m track with
the time taken to walk the middle 10 m recorded.
Participants had two attempts at each condition and
the fastest attempt was used in the analysis. The dual
tasks were completed at the participant’s preferred
speed and had to be completed to set criteria. The
manual task involved carrying a cup of water filled
to 7 mm below the rim with no spills and the cogni-
tive task was a colour classification task where par-
ticipants listened to a pre-recorded audio file and
answered ‘yes’ or ‘no’ in response to hearing the
words ‘red’ or ‘blue’ presented randomly. Freezing
of gait was measured using the New Freezing of
Gait Questionnaire (NFOGQ).12
Participants in both the home-based and centre-
based exercise groups participated in 3 × 60-minute
exercise sessions a week for 10 weeks. Individualised
exercise programs were prescribed by a physiother-
apist with expertise in Parkinson’s disease. The pro-
gram included specific balance and gait exercises
tailored to the individual selected from a menu of
107 Parkinson’s disease specific exercises freely
available at https://www.physiotherapyexercises.
com/. The website provides information about each
exercise, including aims, illustrations and instruc-
tions on how to complete the exercise, dosage and
precautions. Each exercise can be modified to the
participant’s level and the exercise program can be
delivered via an app or in paper format. Participants
completed all exercises during their ‘ON’ phase (i.e.
when Parkinson’s disease medication was optimally
effective). The exercise program focussed on
hypokinesia, bradykinesia and postural instability. It
included everyday activities (e.g. sit to stand),
mobility (e.g. walking on a treadmill or overground),
balance (e.g. anticipatory and reactive) and skill-
based training (e.g. dual task training and cueing).
The exercise program was progressed in week 4 and
week 7 by the physiotherapist, if indicated by the
participant’s ability to effectively complete the set
number of repetitions of each prescribed exercise.
The physiotherapist recorded exercise completed at
the centre and participants recorded the exercise
completed at home using either the app or on paper
as preferred.
4 Clinical Rehabilitation 00(0)
In Block 1 (weeks 1–5) the exercise program was
predominantly centre-based. Two sessions a week
were conducted in a group environment at a univer-
sity clinic and one session a week was completed at
home. The centre-based exercise lasted 60 minutes
with 5–8 participants per class, under the supervi-
sion of an experienced physiotherapist and two
physiotherapy students. The class consisted of a
warm-up (10 minutes), individually prescribed exer-
cise program (45 minutes) and cool down (5 min-
utes). Equipment available at the centre included
treadmills, steps, weight vests, free weights, visual
cues, metronomes and basic sports equipment (e.g.
balls, cones, hurdles). The home-based exercise
lasted 45–60 minutes and included similar exercises
to the centre-based program supported by the
PhysioTherapy eXercises website. Participants also
completed a self-management program for 15 min-
utes per week after a centre-based class. The self-
management program aimed to increase exercise
self-efficacy and promote the development of exer-
cise self-management skills to facilitate completion
of home-based exercise.8,13 It was carried out by an
experienced physiotherapist and involved activities
related to goal setting, identifying barriers to exer-
cise and strategies to facilitate home exercise.
In Block 2 (weeks 6–10) participants were ran-
domised to (i) continue the predominantly centre-
based exercise or (ii) to undertake a home-based
exercise program monitored using telehealth.
Those randomised to the home-based program
completed their exercise independently at home for
45–60 minutes, three times a week. The home-
based exercise program was similar to the centre-
based program completed in Block 1 with
adjustments made for safety and available equip-
ment. Some equipment was loaned to participants
during the trial including weight vests, visual cues
and balls. The physiotherapist remotely-monitored
the participants by telephone during weeks 7 and 9
to review and progress their exercises. Successes
were highlighted and any barriers to adherence or
challenges in completing exercises were addressed.
The full protocol is available in the supplemen-
tal material information.
The feasibility measures and participant character-
istics were analysed and presented using descriptive
statistics. The between group difference of the clinical
measures was examined using analysis of co-variance,
adjusted for baseline scores. The software program
SPSS Statistics (version 25, IBM Corp, Armonk, NY,
USA) was used for all analyses.
Results
The flow of participants in the trial is shown in
Figure 1 and the baseline characteristics of the par-
ticipants are shown in Table 1. All participants had
mild to moderate Parkinson’s disease (Hoehn and
Yahr I–III) and there was little change in the daily
levodopa equivalent dose during the trial for either
group (home-based baseline mean 659 mg (SD
472), post-test mean 663 mg (SD 483); centre-
based baseline mean 512 mg (SD 308) and post-
test mean 526 mg (SD 269).
The time taken by the physiotherapist to pre-
scribe the exercise programs (in week 1, 4 and 7 for
each participant), the time to deliver the centre-
based exercise classes and the time to complete the
remote monitoring are reported in Table 2. During
Block 1, the physiotherapist also spent an addi-
tional 6 hours and 15 minutes delivering the exer-
cise self-management program. Delivery of the
centre-based classes required 98 minutes of thera-
pist time per participant, whereas delivery of the
home-based program required an average of 10 (4)
minutes per participant.
Throughout the intervention adherence to both
home-based and centre-based exercise was high
(Table 3). In Block 2 adherence was 93% (SD 9%)
for the participants in the predominately centre-
based group, and 84% (SD 24%) in the home-based
group showing a trend towards a reduced adherence
in the home-based group (P = 0.115). One partici-
pant in the home-based exercise group experienced
a medical complication unrelated to the exercise in
week 6 and withdrew from the study.
The acceptability questionnaire was completed by
35 participants (88%) at the end of week 5 and 34
(85%) participants at the end of week 10. Statements
about the intervention were rated from strongly disa-
gree to strongly agree (Supplemental Table 1 and
Figure 1). After week 5 all the participants (35)
reported that the exercise was helpful, that exercising
Flynn et al. 5

Assessed for eligibility

Enrollment
(n= 116)

Excluded (n= 75)

♦ Not meeng inclusion criteria (n= 29)
♦ Declined to parcipate (n= 46)
♦ Did not want to aend exercise
class 2 mes per week (n= 20)
♦ Not available for 10 weeks (n= 11)
♦ Declined no reason provided (n= 9)
♦ Lived interstate or overseas (n= 5)
♦ Enrolled in another trial (n= 1)

Baseline assessment

Block 1 (week 1 to week 5)

♦ 2 x 1 hr group exercise class
♦ 1 x 1 hr home exercise session
♦ 1 x 15 min self-management session
(n= 41)

Injured during block 1, while performing

prescribed exercise; unable to connue
exercise program and not randomised
(n= 1)

Randomized (n= 40)

Allocation
Block 2 (week 6 to week 10) Block 2 (week 6 to week 10)
Allocated to Centre-based (n=20) Allocated to Home-based (n=20)
Per week Received allocated intervenon (n=19)
♦ 2 x 1 hr group exercise class ♦ 3 x 1 hr home exercise program per week
♦ 1 x 1 hr home exercise program ♦ Phone call in week 7 and 9
♦ Withdrew (n= 1) due to unrelated
medical complicaon

Post intervenon measures (n=20) Post intervenon measures (n=19)

Analysis
Analysed (n=20) Analysed (n= 19)

Figure 1.  Flow of participants through the trial.

in a group was satisfying and they would recommend
the group to others. At week 10 there were similar
results for participants in the centred-based group.
However, participants in the home-based group
reported that while they found the exercise helpful
and could follow the home exercise program, only
53% of participants agreed that home exercise was
satisfying, and one participant (6%) did not recom-
mend home-based exercise. The acceptability of the
self-management program varied, with responses
6 Clinical Rehabilitation 00(0)

Table 1.  Mean (SD) or number (%) for participants’ characteristics at baseline.

All (n = 40) Home (n = 20) Centre (n = 20)

Age (years) 72 (6.9) 72 (7.3) 71 (6.6)
Sex (female), n (%) 10 (25) 5 (25) 5 (25)
Cognitive status MMSE (0–30) 28.5 (1.6) 28.7 (1.4) 28.3 (1.9)
Disease duration (years) 5.0 (4.9) 5.2 (5.4) 4.7 (4.5)
MDS-UPDRS Motor ‘ON’ (0–132) 29.8 (14.8) 30.7 (15.7) 28.9 (14.3)
Hoehn and Yahr
  Stage 1, n (%) 11 (27) 6 (30) 5 (25)
  Stage 2, n (%) 14 (35) 5 (25) 9 (45)
  Stage 3, n (%) 15 (38) 9 (45) 6 (30)
Fallen in the past 12 months, n (%) 24 (60) 13 (65) 11 (55)
Freezing of gait, n (%) 15 (38) 10 (50) 5 (25)
NFOGQ 5 (7) 6 (7) 4 (7)
Falls risk*
 Low, n (%) 14 (35) 4 (20) 10 (50)
 Moderate, n (%) 11 (27) 8 (40) 3 (15)
 High, n (%) 15 (38) 8 (40) 7 (35)
Daily LED (mg) 586 (400) 659 (472) 512 (308)

NFOGQ: New Freezing of Gait Questionnaire; LED: levodopa equivalent dose; MDS UPDRS motor: Movement Disorders
Society Unified Parkinson’s Disease Rating Scale Motor Subsection; MMSE: mini-mental state examination.
*Falls risk calculated using three step clinical prediction tool clinical (falling in the last year, self-selected gait speed and freezing of
gait in the last month).14

Table 2.  Time taken to develop and deliver exercise programs and to remotely-monitor participants in the home-
based group.

All (n = 40) Home (n = 20) Centre (n = 20)

Weeks 1–5
Time taken to develop program week 1
  Total time (hours) 13.5 6.6 6.9
  Per-participant (minutes)  
  Mean (SD) 20 (6) 20 (5) 21 (7)
  Range 15–45 15–30 15–45
Time taken to develop program week 4
  Total time (hours) 9.8 4.9 4.9
  Per-participant (minutes)  
  Mean (SD) 15 (2) 15 (1) 15 (2)
  Range 10–20 10–15 10–20
Time taken to deliver exercise classes week 1–5
  Total time (hours) 65 N/A N/A
  Per-participant (minutes) 98  
Weeks 6–10
Time taken to develop program week 7a,b
  Total time (hours) 7.2 3.8 3.4
  Per-participant (minutes)  
  Mean (SD) 11 (3) 12 (3) 11 (3)
  Range 5–20 5–20 5–15
(Continued)
Flynn et al. 7

Table 2. (Continued)
All (n = 40) Home (n = 20) Centre (n = 20)
Time taken for remote-monitoring weeks 7 and 9b
  Total time (hours) N/A 6.4 N/A
  Per-participant (minutes)  
  Mean (SD) N/A 10 (4) N/A
  Range N/A 5–20 N/A
Time taken to deliver exercise classes week 6–10
  Total time (hours) N/A N/A 32.5
  Per-participant (minutes) 98

N/A: not applicable.

a
Centre n = 19 time taken to develop program not recorded for 1 centre based participant.
b
Home n = 19 one participant withdrew.

Table 3.  Adherence (%) to each component of the intervention.

All (n = 40) Home (n = 20) Centre (n = 20)

Weeks 1–5
% group exercise sessions completed (10 sessions)
  Mean (SD) 94 (9) 96 (6) 92 (11)
 Range 60–100 80–100 60–100
% self-management sessions completed (5 sessions)
  Mean (SD) 93 (13) 96 (10) 90 (15)
 Range 60–100 60–100 60–100
% home exercise sessions completed (5 sessions)
  Mean (SD) 92 (17) 92 (15) 91 (19)
 Range 40–100 60–100 40–100
Weeks 6–10
% group exercise sessions completed (10 sessions)
  Mean (SD) N/A N/A 94 (8)
 Range N/A N/A 70–100
% home exercise sessions completed (home = 15 sessions, centre = 5 sessions)
  Mean (SD) N/A 84 (24) 92 (16)
 Range N/A 0–100 40–100

N/A: not applicable.

ranging from disagree (24%) to strongly agree (6%).
The majority of participants (80%) chose to use
paper-based instructions and logbook for recording
their exercise. The acceptability of the app was
mixed with only five of the eight participants who
chose to use the app able to use it effectively.
No falls were reported during home-based
exercise. There were three adverse events, all dur-
ing Block 1. Two participants had a non-injurious
fall when exercising at the centre, and were able to
continue the session with no ill effects. One par-
ticipant injured their Achilles tendon when com-
pleting the home exercise program and was
withdrawn from the study prior to randomisation.
Three participants (7.5%) reported pain or muscle
soreness after attending a centre-based exercise
class, with one participant missing a class as a
result. During the 10  weeks, four participants
(three in the centre-based program and one in the
home-based program) reported musculoskeletal
8 Clinical Rehabilitation 00(0)
pain unrelated to the exercise program. This
resulted in three participants missing one exercise
class each and one participant having the exercise
class modified to avoid pain.
There was no difference between groups for any
outcome (Table 4). As there was no difference
between groups, post-hoc analysis of outcomes for
all participants using paired samples t-tests was con-
ducted to reflect the overall effectiveness of the
intervention. There were improvements in balance
and walking speed under all conditions but no
change in freezing of gait (Table 5).
Discussion
The results of this trial show that home-based exer-
cise monitored using telehealth is feasible and
acceptable for people with mild to moderate
Parkinson’s disease. Providing telehealth to partici-
pants exercising at home was substantially more
time efficient for the physiotherapist than delivering
centre-based classes, with remote-monitoring taking
only 19% of the time required to deliver centre
based classes per participant. Both the home-based
and centre based exercise programs had high accept-
ability and adherence, although this was slightly less
in the home-based group. There was limited uptake
of the app to undertake the home-exercise program
suggesting that while people with Parkinson’s dis-
ease may have access to technology, their willing-
ness and ability to use it may be limited. There were
improvements in the clinical outcomes of balance
and gait, but there were no differences between the
groups, indicating that home-based exercise appears
to be similarly effective to centre-based exercise in
the short-term.
This study showed that telehealth can be used to
support people with Parkinson’s disease to exercise
at home. These findings are in line with another
recent pilot trial15 which showed that when home-
based exercise was supported by telehealth, people
with Parkinson’s disease completed more exercise
sessions and spent more time exercising compared to
those who were completing their home program
independently. Furthermore, the results of our study
suggest that home-based exercise supported with tel-
ehealth may be as effective as centre-based exercise
for improving balance and gait in the short-term.
These findings are also consistent with another recent
trial (Gandolfi et al.6) which showed similar balance
and gait outcomes when home-based videogame
exercise supported by telehealth was compared with
centre-based balance exercise in people with mild to
moderate Parkinson’s disease.
While our trial was not powered to detect a dif-
ference between groups the consistent pattern of no
difference between home-based exercise supported
by telehealth and centre-based exercise interven-
tions adds to the growing body of evidence that
location does not impact on the effectiveness of
exercise interventions for people with Parkinson’s
disease.1 This is particularly important in the current
environment where centre-based exercise, including
group based exercise classes may not be feasible due
to COVID-19. Further work in the form of a nonin-
feriority trial16 would be required to determine if
home-based exercise is not inferior to (i.e. as good
as) centre-based exercise. However, such trials
require a large sample size; for example, to deter-
mine if there was no difference between groups on
the MiniBESTest then 108 participants would be
required to be 90% sure that the lower limit of a 95%
confidence interval is above the non-inferiority limit
of a change in score of 3.5 (the minimal detectable
change for people with balance problems).11
It is possible that the home-based exercise in
this trial was effective because it was preceded by
centre-based exercise. This provided people with
Parkinson’s disease with the supervision, feedback
and confidence required to learn how to perform
the exercises safely and effectively. Furthermore,
this may have also reduced the support required
from the physiotherapist to monitor and progress
the home-based program when the participants
transitioned to home exercise alone. Providing ini-
tial centre-based exercise is important to ensure
efficacy, safety and to minimise the risk when peo-
ple exercise at home, especially when home visits
are unavailable or if the telehealth model provided
only involves telephone calls.
Utilising a flexible combination of centre-based
and remotely-monitored home-based exercise pro-
grams has the potential to provide a physiotherapy
service to more people without increasing resource
 Flynn et al.

Table 4.  Mean (SD) of groups, mean (SD) difference within groups and mean (95% CI) difference between groups.

Outcome GROUPS Difference within groups Difference between groups

  Week 0 Week 10 Week 10 − week 0 Week 10 − week 0

  Home Centre Home Centre Home Centre Home minus Centre (95%CI)a,
(n = 20) (n = 20) (n = 19) (n = 20) (n = 19) (n = 20) P-value (n = 39)
Secondary outcomes
MiniBESTest (0–28)b 20.9 (4.4) 22.3 (4.9) 22.3 (4.0) 23.6 (3.5) 1.1 (2.7) 1.3 (3.2) −0.6 (−2.1–1.0), P = 0.47
10 mwt Preferred (m/s) 1.18 (0.25) 1.24 (0.21) 1.38 (0.22) 1.45 (0.41) 0.20 (0.17) 0.21 (0.17) −0.04 (−0.12–0.05), P = 0.42
10 mwt dual task manual (m/s) 1.00 (0.25) 1.06 (0.25) 1.14 (0.32) 1.31 (0.16) 0.14 (0.27) 0.24 (0.27) −0.14 (−0.29–0.02), P = 0.08
10 mwt dual task cognitive (m/s) 1.12 (0.31) 1.12 (0.26) 1.31 (0.24) 1.34 (0.20) 0.19 (0.16) 0.21 (0.16) −0.03 (−0.11–0.06), P = 0.52
10 mwt fast (m/s) 1.52 (0.37) 1.61 (0.29) 1.66 (0.28) 1.79 (0.26) 0.13 (0.19) 0.17 (0.19) −0.07 (−0.17–0.04), P = 0.19
NFOGQ (0–28)c 5.6 (7.3) 4.0 (7.2) 5.8 (8.5) 3.1 (6.4) −0.1 (2.5) −0.9 (5.6) 1.04 (−1.78–3.85), P = 0.46

CI: confidence interval; Centre: predominately centre-based group; Home: remotely-monitored home-based group; m/s: metres per second; NFOGQ: New Freezing of Gait
Questionnaire; 10 mwt: 10 meter walk test.
a
Values are adjusted for baseline (pre-test) score based on analysis of covariance ANCOVA.
b
Higher score indicates better balance.
c
Higher score indicates greater freezing of gait
9
10 Clinical Rehabilitation 00(0)

Table 5.  Clinical outcome measures for all participants pre and post intervention Mean (SD), difference (SD), 95%
CI and P-value.

Week 0 Week 10 Difference (n = 39) P-value

(n = 39) (n = 39)

  Mean (SD) Mean (SD) Mean (SD) 95% CI

MiniBESTest (0–28)a 21.8 (4.5) 22.9 (3.8) −1.2 (2.8) −2.1–−0.2 P = 0.014*
10 mwt Preferred (m/s) 1.21 (0.23) 1.41 (0.19) −0.20 (0.17) −0.26–−0.15 P < 0.0001*
10 mwt Dual task manual (m/s) 1.03 (0.25) 1.23 (0.26) −0.19 (0.27) −0.28–−0.11 P < 0.0001*
10 mwt Dual task cognitive (m/s) 1.13 (0.28) 1.33 (0.22) −0.20 (0.16) −0.25–−0.15 P < 0.0001*
10 mwt Fast (m/s) 1.58 (0.33) 1.72 (0.27) −0.15 (0.19) −0.21–−0.09 P < 0.0001*
NFOGQ (0–28)b 4.9 (7.3) 4.4 (7.5) 0.5 (4.3) −0.9−1.9 P = 0.487

m/s: metres per second; NFOGQ: New Freezing of Gait Questionnaire; 10 mwt: 10 meter walk test.
a
Higher score indicated better balance.
b
Higher score indicates greater freezing of gait.
*P < 0.05.

use. This trial enabled, per participant, 15 hours of
home-based exercise to be performed with only
20  minutes of physiotherapist time. Further
research into the number of centre-based sessions
required prior to safely commencing home-based
exercise, and the long-term acceptability, sustaina-
bility, cost-effectiveness and efficacy of this model
is required. Consideration also needs to be given to
determining the appropriate level of supervision
and ensuring the physiotherapist can effectively
monitor, progress and provide feedback during the
home-based program. If this incorporates the use
of technology, the physiotherapist needs to ensure
that it can be used effectively.
Despite the results suggesting that home-based
exercise might be as effective as centre-based
exercise, participants were less satisfied overall
when exercising at home. This suggests that the
exercise self-management program and telehealth
did not fully meet the needs of participants. The
short amount of time allocated to the self-manage-
ment program may have impacted on its effective-
ness. However, other factors, such as social
interaction and reduced feedback may also influ-
ence the level of satisfaction with home-based
exercise.4 Classeon et al.17 reported that people
with Parkinson’s disease found group-based
classes not only addressed physical abilities but
also addressed social and emotional needs and
assisted people to cope with living with Parkinson’s
disease. An increased focus on social interaction
using telehealth may lead to increase satisfaction
with completing home-based exercise and this
could be trialled in future studies.
This was a pragmatic trial designed to reflect
clinical practice, which resulted in some limitations.
These included recruiting participants with a wide
range of experience completing exercise at home,
with some participants already undertaking regular
home-based exercise prior to enrolling in the trial.
Another limitation was the recording of the adher-
ence to the home-based exercise program, which
was highly variable between participants. Given the
limitations of self-reporting, future studies should
include an objective measure of the exercise com-
pleted, for example using wearable technology.
Further to this, the study had a small sample size and
recruitment rate for this trial (35%) was lower than
previous trials which have compared home-based
and centre based exercise in people with Parkinson’s
disease.6,18 The length of the intervention (10 weeks)
contributed to some people declining to participate,
and 25 people declined to be involved as they could
not commit to attending the centre twice a week. As
such, our findings may have overestimated the
acceptability of the intervention.
This study adds to the growing evidence tele-
health can be used to support people with
Parkinson’s disease to exercise at home. This model
of care has the potential to allow increased access to
Flynn et al. 11
physiotherapy as it requires less therapist time than
ongoing centre-based programs. Further investiga-
tion is needed, with larger sample size, on the long-
term efficacy and sustainability of this model.
Clinical messages
•• Home-based exercise for people with
Parkinson’s disease which is prescribed
by a physiotherapist and monitored using
telehealth is feasible, and acceptable.
•• Home-based exercise monitored with tel-
ehealth took less time to deliver than
group sessions.
•• Home-based exercise using telehealth
has similar effects to centre-based exer-
cise in the short term.
Acknowledgements
The authors would like to thank the participants and
assessors (Christine O’Brien and Emma Eaton) who
assisted in this study.
Author contributions
AF, EP, CC, SD and NA contributed to the concept and
design of the study, AF and EP provided the interven-
tion, AF, EP, SD, CC and NA completed the analysis
and interpretation of the results, AF, EP, SD, CC and NA
contributed to writing the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication
of this article: This work was supported by funding from
Parkinson’s ACT.
ORCID iD
Allyson Flynn https://orcid.org/0000-0002-4235-5518
Supplemental material
Supplemental material for this article is available online.
References
1. Flynn A, Allen NE, Dennis S, et al. Home-based pre-
scribed exercise improves balance-related activities in
people with Parkinson’s disease and has benefits similar to
centre-based exercise: a systematic review. J Physiother
2019; 65(4): 189–199.
2. Allen NE, Sherrington C, Suriyarachchi GD, et al.
Exercise and motor training in people with Parkinson’s
disease: a systematic review of participant characteris-
tics, intervention delivery, retention rates, adherence, and
adverse events in clinical trials. Parkinsons Dis 2012;
2012: 954328.
3. Wallén MB, Hagströmer M, Conradsson D, et al. Long-
term effects of highly challenging balance training in
Parkinson’s disease – a randomized controlled trial. Clin
Rehabili 2018; 32(11): 1520–1529.
4. O’Brien C, Clemson L and Canning CG. Multiple fac-
tors, including non-motor impairments, influence deci-
sion making with regard to exercise participation in
Parkinson’s disease: a qualitative enquiry. Disabil Rehabil
2016; 38(5): 472–481.
5. Dorsey ER and Topol EJ. State of telehealth. N Engl J
Med 2016; 375(2): 154–161.
6. Gandolfi M, Geroin C, Dimitrova E, et al. Virtual real-
ity telerehabilitation for postural instability in Parkinson’s
disease: a multicenter, single-blind, randomized, con-
trolled trial. Biomed Res Int 2017; 2017: 7962826.
7. Song J, Paul SS, Caetano MJD, et al. Home-based step
training using videogame technology in people with
Parkinson’s disease: a single-blinded randomised con-
trolled trial. Clin Rehabili 2018; 32(3): 299–311.
8. Ellis TD, Cavanaugh JT, DeAngelis T, et al. Comparative effec-
tiveness of mhealth-supported exercise compared with exer-
cise alone for people with Parkinson disease: randomized
controlled pilot study. Phys Ther 2019; 99(2): 203–216.
9. van der Kolk NM, de Vries NM, Kessels RP, et al. Effectiveness
of home-based and remotely supervised aerobic exercise in
Parkinson’s disease: a double-blind, randomised controlled
trial. Lancet Neurol 2019; 18(11): 998–1008
10. Folstein M, Folstein S and McHugh P. Mini mental state. “A
practical method for grading the cognitive state of patients
for the clinician.” J Psychiatr Res 1975; 12: 189–198.
11. Godi M, Franchignoni F, Caligari M, et al. Comparison
of reliability, validity, and responsiveness of the mini-
BESTest and Berg Balance Scale in patients with balance
disorders. Phys Ther 2013; 93(2): 158–167.
12. Nieuwboer A, Rochester L, Herman T, et al. Reliability of
the new freezing of gait questionnaire: agreement between
patients with Parkinson’s disease and their carers. Gait
Posture 2009; 30(4): 459–463.
13. Keus S, Munneke M, Graziano M, et al. European
physiotherapy guideline for Parkinson’s disease. The
Netherlands: KNGF/ParkinsonNet, 2014.
14. Paul SS, Canning CG, Sherrington C, et al. Three sim-
ple clinical tests to accurately predict falls in people with
Parkinson’s disease. Mov Disord 2013; 28(5): 655–662.
12 Clinical Rehabilitation 00(0)

15. Lai B, Bond K, Kim Y, et al. Exploring the uptake and imple-
mentation of tele-monitored home-exercise programmes
in adults with Parkinson’s disease: a mixed-methods pilot
study. J Telemed Telecare 2020; 26(1–2): 53–63.
16. Piaggio G, Elbourne DR, Pocock SJ, et al.; CONSORT
Group. Reporting of noninferiority and equivalence ran-
domized trials: extension of the CONSORT 2010 state-
ment. Jama. 2012; 308(24): 2594–2604.
17. Claesson IM, Ståhle A and Johansson S. Being limited
by Parkinson’s disease and struggling to keep up exercis-
ing; is the group the glue? Disabil Rehabil 2020; 42(9):
1270–1274.
18. King LA, Wilhelm J, Chen Y, et al. Effects of group, indi-
vidual, and home exercise in persons with Parkinson dis-
ease: a randomized clinical trial. J Neurol Phys Ther 2015;
39(4): 204–212.