Research Centers Collaborative Network Workshop on Digital Health Approaches to Research in Aging.

Digital health technologies are ubiquitous in the healthcare landscape. Older adults represent an important user group who may benefit from improved monitoring of physical and cognitive health and in-home access to care, but there remain many barriers to widespread use of digital health technologies in gerontology and geriatric medicine. The National Institute on Aging Research Centers Collaborative Network convened a workshop wherein geriatricians and gerontological researchers with expertise related to mHealth and digital health applications shared opportunities and challenges in the application of digital health technologies in aging. Discussion broadly centered on 2 themes: promises and challenges in (i) the use of ecological momentary assessment methodologies in gerontology and geriatric medicine, and (ii) the development of health promotion programs delivered via digital health technologies. Herein, we summarize this discussion and outline several promising areas for future research.

Considerations for developing a targeted amino acid supplement for people with Parkinson's disease that promotes health while accounting for pathophysiology and medication interference.

For individuals with Parkinson's disease (PD), dietary habits affect disease symptoms, progression, and overall health. Protein consumption is of great interest because of the direct and indirect effects of specific amino acids (AAs) on disease progression and interference with levodopa medication. Proteins comprise 20 distinct AAs with varying effects on overall health, disease progression, and medication interference. Therefore, it is important to consider both the potential beneficial and detrimental effects of each AA when considering supplementation for an individual with PD. Such consideration is of particular importance because PD pathophysiology, altered dietary patterns associated with PD, and competitive absorption with levodopa have been shown to result in characteristically altered AA profiles (eg, some AAs are stored in excess while others are deficient). To address this problem, considerations for the development of a precision nutritional supplement that targets AAs specific to the needs of people with PD are discussed. The objective of this review is to provide a theoretical framework for such a supplement, detailing the current state of knowledge relating relevant evidence to such a supplement, and highlighting areas of future research. Specifically, the general need for such a supplement is discussed before a systematic examination is provided of the potential benefits and risks of dietary supplementation of each AA in people with PD. As a part of this discussion, evidence-based recommendations are provided regarding the inclusion or exclusion of each AA for such a supplement for people with PD, and areas are highlighted where additional research is needed.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association.

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Are Mobile Persons With Parkinson Disease Necessarily More Active?

BACKGROUND AND PURPOSE: Walking activity in persons with Parkinson disease (PD) is important for preventing functional decline. The contribution of walking activity to home and community mobility in PD is poorly understood. METHODS: Cross-sectional baseline data (N = 69) were analyzed from a randomized controlled PD trial. The Life-Space Assessment (LSA) quantified the extent, frequency, and independence across 5 expanding levels of home and community mobility, producing individual subscores and a total score. Two additional summed scores were used to represent mobility within (Levels 1-3) and beyond (Levels 4-5) neighborhood limits. An accelerometer measured walking activity for 7 days. Regression and correlation analyses evaluated relationships between daily steps and mobility scores. Mann-Whitney U tests secondarily compared differences in mobility scores between the active and sedentary groups. RESULTS: Walking activity contributed significantly to the summed Level 1-3 score (ß = 0.001, P = 0.004) but not to the summed Level 4-5 (ß = 0.001, P = 0.33) or total (ß = 0.002, P = 0.07) scores. Walking activity was significantly related to Level 1 (ρ = 0.336, P = 0.005), Level 2 (ρ = 0.307, P = 0.010), and Level 3 (ρ = 0.314, P = 0.009) subscores. Only the summed Level 1-3 score (P = 0.030) was significantly different between the active and sedentary groups. DISCUSSION AND CONCLUSIONS: Persons with PD who demonstrated greater mobility beyond the neighborhood were not necessarily more active; walking activity contributed more so to home and neighborhood mobility. Compared with LSA total score, the Level 1-3 summed score may be a more useful participation-level measure for assessing the impact of changes in walking activity.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A349).

Impact of COVID-19 on services for people with disabilities and chronic health conditions.

BACKGROUND: People with disabilities and chronic health conditions rely on a range of services and supports to complete daily tasks, maintain health, and participate in the community. Preliminary research suggests the COVID-19 pandemic greatly disrupted these services and this population may be particularly susceptible to unemployment. OBJECTIVE: Describe employment and service disruptions for individuals with disabilities and chronic health conditions during the onset of community-based spread of COVID-19 in the United States. METHODS: Adults with disabilities and chronic health conditions completed online surveys to report employment and service changes via multiple choice and open-ended questions. Multiple choice questions were analyzed using descriptive statistics; open-ended responses were coded using content analysis. RESULTS: Participants (n = 109): 79.8% female, 88.1% white, 77.121% completed a 4-year college degree or greater, 61.4% had annual income ≥$45,000. Only 14.9% of survey respondents reported disruptions in employment. On average, 54.0% of service changes were due to discontinuation, including loss of physical therapy, job coaching, community organizations, transportation, and peer supports. Other changes included a shift to virtual service delivery and family members taking the role of service providers. CONCLUSIONS: Individuals with chronic health conditions and disabilities experienced service disruptions, even in a sample with considerably more economic, social, and educational privilege than the general population of people with chronic health conditions and disabilities in the United States.

Evidence for Early and Regular Physical Therapy and Exercise in Parkinson's Disease.

Advances in medical management of Parkinson's disease (PD) have resulted in living longer with disability. Although disability worsens over the course of the disease, there are signs of disability even in the early stages. Several studies reveal an early decline in gait and balance and a high prevalence of nonmotor signs in the prodromal period that contribute to early disability. There is a growing body of evidence revealing the benefits of physical therapy and exercise to mitigate motor and nonmotor signs while improving physical function and reducing disability. The presence of early disability coupled with the benefits of exercise suggests that physical therapy should be initiated earlier in the disease. In this review, we present the evidence revealing early disability in PD and the effectiveness of physical therapy and exercise, followed by a discussion of a secondary prevention model of rehabilitation to reduce early disability and optimize long-term outcomes.

Effort-Based Decision-Making for Exercise in People with Parkinson's Disease.

BACKGROUND: People with Parkinson's disease (PwPD) are less active than their age-matched peers. Non-motor symptoms, specifically, deficient motivation, may influence decision-making for exercise due to the impaired mesolimbic dopaminergic pathway. OBJECTIVE: The purpose of this study was to determine if effort-based decision-making for physical effort was different in PwPD compared to healthy controls. We sought to determine the relationship between effort-based decision making for exercise and a discrete motor task as well as the impact of components of motivation on decision-making for physical effort in PwPD. METHODS: An effort-based decision-making paradigm using a discrete motor task (button pressing) and a continuous exercise task (cycling) was implemented in 32 PwPD and 23 healthy controls. Components of motivation were measured using the Apathy Scale and the Temporal Experience of Pleasure Scale- Anticipatory Pleasure scale. RESULTS: The presence of Parkinson's disease (PD) did not moderate decisions for either physical effort task. There was a moderate correlation between decisions for both tasks, within each group. The anticipation of pleasure and apathy were predictors of decisions for both physical effort tasks in PwPD, but not in healthy controls. CONCLUSION: PwPD responded similarly to effort and reward valuations compared to those without PD. Individuals were consistent in their decisions, regardless of the physical effort task. The anticipation of pleasure and apathy were significant predictors of decisions for exercise in PwPD only. Increased anticipation of pleasure, reduction of apathy, and the use of rewards may enhance engagement in high effort exercise among PwPD.

Design of the WHIP-PD study: a phase II, twelve-month, dual-site, randomized controlled trial evaluating the effects of a cognitive-behavioral approach for promoting enhanced walking activity using mobile health technology in people with Parkinson-disease.

BACKGROUND: Parkinson disease (PD) is a debilitating and chronic neurodegenerative disease resulting in ambulation difficulties. Natural walking activity often declines early in disease progression despite the relative stability of motor impairments. In this study, we propose a paradigm shift with a "connected behavioral approach" that targets real-world walking using cognitive-behavioral training and mobile health (mHealth) technology. METHODS/DESIGN: The Walking and mHealth to Increase Participation in Parkinson Disease (WHIP-PD) study is a twelve-month, dual site, two-arm, randomized controlled trial recruiting 148 participants with early to mid-stage PD. Participants will be randomly assigned to connected behavioral or active control conditions. Both conditions will include a customized program of goal-oriented walking, walking-enhancing strengthening exercises, and eight in-person visits with a physical therapist. Participants in the connected behavioral condition also will (1) receive cognitive-behavioral training to promote self-efficacy for routine walking behavior and (2) use a mHealth software application to manage their program and communicate remotely with their physical therapist. Active control participants will receive no cognitive-behavioral training and manage their program on paper. Evaluations will occur at baseline, three-, six-, and twelve-months and include walking assessments, self-efficacy questionnaires, and seven days of activity monitoring. Primary outcomes will include the change between baseline and twelve months in overall amount of walking activity (mean number of steps per day) and amount of moderate intensity walking activity (mean number of minutes per day in which > 100 steps were accumulated). Secondary outcomes will include change in walking capacity as measured by the six-minute walk test and ten-meter walk test. We also will examine if self-efficacy mediates change in amount of walking activity and if change in amount of walking activity mediates change in walking capacity. DISCUSSION: We expect this study to show the connected behavioral approach will be more effective than the active control condition in increasing the amount and intensity of real-world walking activity and improving walking capacity. Determining effective physical activity interventions for persons with PD is important for preserving mobility and essential for maintaining quality of life. Clinical trials registration NCT03517371, May 7, 2018. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03517371. Date of registration: May 7, 2018. Protocol version: Original.

Accuracy of Activity Trackers in Parkinson Disease: Should We Prescribe Them?

Background: Wearable, consumer-grade activity trackers have become widely available as a means of monitoring physical activity in the form of step counts. However, step counts may not be accurate in persons with Parkinson disease (PD) due to atypical gait characteristics. Objective: This study aimed to investigate the accuracy of 4 consumer-grade activity trackers in individuals with PD while ambulating during continuous and discontinuous walking tasks. Design: This study used a cross-sectional design. Methods: Thirty-three persons with PD (Hoehn & Yahr stages 1-3) donned 4 models of activity trackers on the less affected side of their bodies. Participants performed 2 continuous walking tasks (2-minute walk tests at comfortable and fast speeds) and 2 discontinuous walking tasks (a simulated household course and an obstacle negotiation course) in an outpatient setting. Bland-Altman plots and intraclass correlation coefficients [ICC(2,1)] were computed as a measure of agreement between actual steps taken (reference standard: video recording) and steps recorded by each tracker. Results: The accuracy of the activity trackers varied widely, with ICCs ranging from -0.03 to 0.98. Overall, the most accurate device across all tasks was the Fitbit Zip, and the least accurate was the Jawbone Up Move during the simulated household course. All activity trackers were more accurate for continuous walking tasks compared with discontinuous walking tasks. Waist-mounted devices were more accurate than wrist-mounted devices with continuous tasks. Bland-Altman plots revealed that all activity trackers underestimated step counts. Limitations: All walking tasks were measured over relatively short distances. Conclusions: In persons with mild-to-moderate PD, waist-worn activity trackers may be prescribed to monitor bouts of continuous walking with reasonable accuracy; however, activity trackers have little utility in monitoring discontinuous walking common in household settings.

Peer Coaching Through mHealth Targeting Physical Activity in People With Parkinson Disease: Feasibility Study.

BACKGROUND: Long-term engagement in exercise and physical activity mitigates the progression of disability and increases quality of life in people with Parkinson disease (PD). Despite this, the vast majority of individuals with PD are sedentary. There is a critical need for a feasible, safe, acceptable, and effective method to assist those with PD to engage in active lifestyles. Peer coaching through mobile health (mHealth) may be a viable approach. OBJECTIVE: The purpose of this study was to develop a PD-specific peer coach training program and a remote peer-mentored walking program using mHealth technology with the goal of increasing physical activity in persons with PD. We set out to examine the feasibility, safety, and acceptability of the programs along with preliminary evidence of individual-level changes in walking activity, self-efficacy, and disability in the peer mentees. METHODS: A peer coach training program and a remote peer-mentored walking program using mHealth was developed and tested in 10 individuals with PD. We matched physically active persons with PD (peer coaches) with sedentary persons with PD (peer mentees), resulting in 5 dyads. Using both Web-based and in-person delivery methods, we trained the peer coaches in basic knowledge of PD, exercise, active listening, and motivational interviewing. Peer coaches and mentees wore FitBit Zip activity trackers and participated in daily walking over 8 weeks. Peer dyads interacted daily via the FitBit friends mobile app and weekly via telephone calls. Feasibility was determined by examining recruitment, participation, and retention rates. Safety was assessed by monitoring adverse events during the study period. Acceptability was assessed via satisfaction surveys. Individual-level changes in physical activity were examined relative to clinically important differences. RESULTS: Four out of the 5 peer pairs used the FitBit activity tracker and friends function without difficulty. A total of 4 of the 5 pairs completed the 8 weekly phone conversations. There were no adverse events over the course of the study. All peer coaches were "satisfied" or "very satisfied" with the training program, and all participants were "satisfied" or "very satisfied" with the peer-mentored walking program. All participants would recommend this program to others with PD. Increases in average steps per day exceeding the clinically important difference occurred in 4 out of the 5 mentees. CONCLUSIONS: Remote peer coaching using mHealth is feasible, safe, and acceptable for persons with PD. Peer coaching using mHealth technology may be a viable method to increase physical activity in individuals with PD. Larger controlled trials are necessary to examine the effectiveness of this approach.

Test-Retest Reliability and Minimal Detectable Change for the 10-Meter Walk Test in Older Adults With Parkinson's disease.

BACKGROUND AND PURPOSE: Measurement of gait performance in individuals with Parkinson's disease (PD) can be challenging because of the daily fluctuations in performance and the progressive nature of the condition. The 10-Meter Walk Test (10MWT) is commonly used to measure gait speed of individuals with gait limitations. Existing research on the 10MWT in individuals with PD controls for many variables inherent to this condition, rendering the results of this test in settings where these variables are not controlled questionable. The purpose of this study was to estimate under commonly encountered clinical conditions the test-retest reliability and the minimal detectable change (MDC) of gait speed and step frequency determined during the 10MWT in individuals with PD. METHODS: The 10MWT was administered by 2 testers, on 35 participants, across 2 sessions, separated by 5 to 14 days. Gait speed was measured using a hand-held stopwatch, and step frequency was assessed through visual observation. Test-retest reliability was calculated using the intraclass correlation coefficient (ICC) and the MDC was calculated using the standard error of measurement (SEM). RESULTS AND DISCUSSION: Comfortable and fast gait speeds demonstrated excellent reliability between sessions (ICC = 0.92 and 0.96, respectively). The corresponding MDCs were 0.22 and 0.23 m/s, respectively. The test-retest reliability for step frequency was moderate for comfortable gait speed and good for fast gait speeds (ICC = 0.73 and 0.82, respectively). The corresponding MDCs were 15.1 and 17.4 steps per minute for comfortable and fast step frequency, respectively. CONCLUSIONS: Under both comfortable and fast conditions, measurements of gait speed and step frequency during the 10MWT are reliable between sessions in individuals with PD.

Effects of visual environment on quiet standing by young and old adults.

The authors manipulated the circumstances in which individuals are typically embedded when standing upright by manipulating the intensity of light and the stationary structure of the environment. They expected that the manipulations would affect 12 older participants (aged 65-82 years) more than it would 12 younger participants (aged 22-24 years). Linear (e.g., total path length) and nonlinear (e.g., maximum line length of recurrent points in phase space) measures of the center of pressure time series confirmed that expectation. Moreover, for some measures, there was a suggestion that participants' visual contrast sensitivity (an index of neurophysiological age) was a more important contributing factor overall than was their chronological age. In the Discussion, the authors highlight the significance of interactive effects of environmental, organismic, and task constraints on quiet standing.