Comparison of an online and centre-based group exercise program to improve balance for people with Parkinson's Disease

Up to 10 participants will complete 16 one-hour synchronous group telerehabilitation sessions of a multimodal balance exercise program conducted twice weekly over 8 weeks at each participant’s home. The sessions will be remotely instructed by a movement disorder physiotherapist with 17 years of clinical experience and 5 years of experience delivering telerehabilitation. All telerehabilitation sessions will be also assisted by an allied health assistant remotely. Participants will be provided with a pair of 1-kilogram dumbbells to be used during the program. The type of exercises will remain the same over 8 weeks, and the level of difficulty, intensity, speed, or complexity will be progressively titrated upwards depending on the mastery of exercise as a whole group. The physiotherapist leading the group will assess their level of mastery and confidence from visual observation of participants’ reaction to the physical movements and their verbal feedback. They will be encouraged to exercise with a large amplitude of movement and at a moderate to vigorous intensity level (rated 4 to 8) as measured by the Borg Rating of Perceived Exertion (scale of 1 to 10). Participants will be advised on safety procedures such as having the support base within reach of arms and a water bottle for hydration. The physiotherapist will instruct participants in the group to perform a wide range of exercises in both sitting and standing positions. Participants will be asked to continue each exercise for up to 1 minute before transitioning to the next. The exercises will be structured using the “FASTC” principle — an acronym for Functional training, Amplitude training, Strategy training, Timing, and Cognitive training—which are key components in prescribing physiotherapy exercises for people with PD. The types of exercises include walking, sit-to-stand transitions, martial arts movements, stepping, balance, strength, and flexibility exercises. All participants will perform the same exercise demonstrated by the physiotherapist. However, the level of balance challenge may be tailored to each individual’s ability and confidence using upper limbs to anchor to the support base (back of the chair). Participants will be initially asked to decide the level of balance challenge by themselves, with some guidance on their options. For example, single leg standing exercises can be completed anchoring on the back of the chair in one of three ways: with one hand on the support base, or one fingertip or no hands at all. Similarly, forward lunge stepping exercises can be completed with one hand on the support base, no hands or extending both arms sideways while stepping forward. The physiotherapist will monitor their performance and advise on altering the level of difficulty or suggesting any modifications. The level of difficulty, intensity, speed and complexity will be tailored and progress for the group throughout the course of this program. These parameters will also be adjusted individually in a self-directed manner by participants or modified by the physiotherapist through observation of participants’ physical reactions to each exercise. Complexity will be introduced by adding a dual cognitive or manual task component to the exercise movement. For example, participants will be asked to name European cities while executing forward lunge stepping exercises, or to count down from 50 by 3s while executing squats with both arms extending forward. The actual time spent performing exercises will be recorded in minutes for each session. The allied health assistant will also record duration of any interruptions due to internet connectivity issues and any periods of non-participation for each participant. Intervention fidelity will be assessed using a checklist completed by the allied health assistant during each session. The physiotherapist will review the checklist after each session. Participant adherence will be defined as the attendance rate over the 16 sessions.