The emerging care models for Parkinson’s disease (PD) are using technology to deliver a hybrid approach to care, where in-person and online sessions can complement each other.  The use of technology is an obvious solution to facilitate access to care, reduce the burden of transportation, lower costs and lessen demands on care partners.

Exercise can also be delivered remotely. However, some barriers still need to be overcome, including limited evidence for benefits and safety, insurance models, and technological access & knowledge asymmetries, before it reaches its true usefulness and widespread implementation.

Delivering exercise online comes down to 3 key questions: Does it provide equivalent or even superior clinically relevant outcomes that benefit care (efficacy)? Can it safely be applied with sufficient intensity (safety)? And how do we overcome the barriers to its ongoing use (compliance)?

A click of efficacy
Preliminary evidence in PD shows that dance, boxing, and dual-task training are three different modalities of training with perceived benefits and safety in online formats. Until further evidence, there is no reason to think the benefits of other programs would be less than in person, provided that individuals with PD are fully engaged and have positive, safe experiences from the exercise classes. This is a fundamental piece for efficacy, safety, and compliance.

Obtaining clinical benefits with online exercise ultimately depends on what we choose and how we implement it. Are we aiming to replace in-person sessions, or is it only a complementary part of an exercise strategy? Each approach provides unique benefits.

For example, an online exercise program is an excellent option if you are trying to exercise within some constraints (adverse weather, transportation issues, limited time, and financial limitations). But, it might also be an excellent option to complement your rehabilitation program with ongoing exercise. Notably, in a time where people with PD are often guided to follow exercise guidelines that have the person exercising different domains on different days, the process of obtaining sufficient exercise quickly fills up the week. Would training strength and balance in the gym twice a week and doing online dance/boxing (aerobic) three times a week seem like a more reasonable and achievable amount of exercise for most people with PD?

In an ideal situation, combining in-person and virtual exercise options will be preferred to achieve the best of both worlds. Exercises that challenge balance might be more appropriately applied in person to allow pushing the limits of balance to achieve better results with fewer risks. Exercises requiring less supervision, such as dance, boxing, or seated exercises, are considered safe in online formats.

A click of safety
Particular to delivering exercise virtually, there are real concerns around safely integrating activities commonly used in PD at the same level of intensity as in-person. Safe, evidence-based practices must be a priority for care in all settings, including online. Without robust evidence and guidelines, professionals may favor unnecessary procedures, foster unrealistic expectations in people with PD (particularly those with less favorable profiles), and can ultimately be putting individuals at risk of falls and/or injury.

Safety with online exercise ultimately depends on who applies, what is applied, and how we use it.  Just as they do in person, online exercise programs led by professionals with PD-specific expertise can better guarantee the person's safety. These professionals can better select which exercises to apply and adapt to individuals at risk and for any changes in needs over time. Additionally, increasing research regarding online exercise with a focus on specific individuals at-risk due to disease severity and raising awareness for reporting adverse events in research more precisely can be additional courses of action to enhance safety.

A click of compliance
We all know that people attend exercise classes not just for the exercise but for the opportunity to meet and interact with other individuals with similar interests. The human factor and relationship-building experience are primary reasons why people attend and come back (it’s the glue). So, can technology also facilitate chit-chat and social connections? How can we enhance social engagement in online activities?

One common way used to facilitate engagement is to promote an interactive chit-chat moment before and after class, after which microphones go off and one-way communication happens until the end. Is this enough? No! We must be more willing to experiment and refine with more disruptive models. For example, having the person’s active voice and interaction during the activities in a gamified manner induces more motivation and allows the instructor to monitor adherence and safety (https://youtu.be/O0eDMGcoCRM). Other examples can include promoting moments where one of the persons with PD also assumes the teacher role during an exercise (https://youtu.be/eTralrd_kMA). Also, having friendly competitions among 2 participants on display to others allows for moments of fun social connection (https://youtu.be/AE2Pw65jQik).

The more clearly, we imagine, adopt and adjust online exercise in our future care models, the sooner the growing number of individuals with PD will benefit from its use in a safe and fun manner. Increasing public interest in online exercise programs may also positively influence the direction of clinical research and advance clinical practice. All these actions can begin to guide us away from care disparities and promote better care for people with PD.

Josefa Domingos is a Physiotherapist Parkinson Specialist, PhD Student at Radboud University Center, Nijmegen, Netherlands. She is also a speaker at WPC 2023 and a Renewal Room Committee Planning Member. View the Scientific Program here. Find Josefa on Twitter: @DomingosJosefa

Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not necessarily reflect the opinions or positions of the World Parkinson Coalition®