Augmented reality rehabilitation at home for adults with Parkinson's disease: a feasibility study

Augmented reality rehabilitation at home for adults with Parkinson's disease: a feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Augmented reality rehabilitation at home for adults with Parkinson's disease: a feasibility study Caroline Gill, Alexandra Whelan, Cheryl Bell, Ansa Sunil, Rory J O'Connor This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9117546/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Parkinson’s is a neurodegenerative condition causing movement impairments and increasing peoples’ risk of falls. People with Parkinson’s (PwP) are advised to exercise regularly to maintain their mobility and balance, specifically using sensory cueing, which is beneficial for freezing of gait, one of the most difficult apsects of living with Parkinson’s. Maintaining an exercise programme to achieve the effective dose of rehabilitation can be challenging and becomes more difficult over time, leading to reduced function and deteriorating quality of life. Objective This study aimed to investigate the use of Strolll, a novel cueing-based rehabilitation programme for PwP, delivered through augmented reality headsets at home. Methods Thirty PwP were recruited. Each participant had baseline and follow-up assessments in clinic. Individual game-based rehabilitation was prescribed for home use for 6 weeks with remote monitoring and weekly telephone appointments. The primary outcome measure was the Timed-Up-and-Go (TUG). Secondary outcome measures included the Lindop Parkinson’s Assessment Scale (LPAS). Statistical analysis comprised parametric and non-parametric methods appropriate to the data. Results Twenty-eight participants completed 6 weeks’ rehabilitation; two participants withdrew. Mean TUG improved from 13.2s to10.3s (p < 0.001) and LPAS improved from 27 to 29 (p < 0.01). No falls, near falls or other adverse events were reported. Conclusion Novel game-based exercises through augmented reality were successfully used to deliver rehabilitation for PwP in their homes with participants’ mobility improved and no adverse effects reported. A multi-site randomised controlled trial (NIHR206530) based on the results of this feasibility trial has started, which will investigate the clinical- and cost-effectiveness of this technology. Trial Registration: ClinicalTrials.gov No.: NCT05794542 Registered 29-10-2023 Physical Medicine & Rehab Rehabilitation Parkinson’s disease Augmented Reality Background Parkinson’s disease is a progressive neurological condition that profoundly affects a person’s functioning. 1 It is the most rapidly growing neurological condition globally and affects more than 153,000 people in the UK. 2 There is a rising prevalence with age, and projections indicate that the number of people living with Parkinson’s will double in the next two decades, escalating the demands on health and social care services. 3 Each year in the UK, over 17,300 people are newly diagnosed with Parkinson’s. Men are 1.5 times more likely to develop Parkinson’s than women. 4 There are three main characteristic clinical features of Parkinson’s – tremor, bradykinesia and rigidity. These motor impairments affect balance and gait, particularly walking speed, and frequently lead to falls. 1 Many people with Parkinson’s experience cognitive impairment, sleep disturbance, anxiety or depression, further complicating people’s experience with the condition. The UK’s Department of Health and Social Care guidelines for the adult population recommend 150 minutes of moderate intensity physical activity, equivalent to 30 minutes per day for 5 days a week, or 75 minutes of vigorous intensity physical activity for everyone each week. 5 Exercise can improve physical health as well as improve sleep quality, mental health and well-being. This is no different for people living with Parkinson’s. Indeed, people living with Parkinson’s are encouraged to engage in a daily exercise programme to maintain their mobility, independence, and quality of life. Studies have shown that exercise can be a neuroprotective mechanism in Parkinson’s and improve symptoms. 6,7 However, it can be difficult for people with Parkinson’s to perform exercises because of their motor impairments. In addition, as their gait and balance deteriorate, their fear of falls can increase, and participating in exercise groups outside the home or maintaining engagement in a generic home exercise programme becomes more difficult. All of these factors can lead to reduced function, independence and quality of life. 8 The National Institute for Health and Care Excellence (NICE) in the UK recommends offering Parkinson's-specific therapy to people who are experiencing balance or motor impairments. 9 These therapies are most frequently delivered in specialised clinics, usually in hospital outpatient departments. Attending hospital appointments can be difficult and inconvenient for many people, particularly for those whose mobility is already impaired. 10 Home-based community services are costly, often stretched and not always available when needed. Importantly, therapy, whether during a clinic or a home appointment, will not be accessible to a person with Parkinson’s experiencing an “off” period, when the effect of medication has worn off. As Parkinson’s disease continues to rise in prevalence, it is imperative that therapy services adapt to meet the increasing and evolving demands. As Parkinson’s progresses, people may experience episodes of ‘freezing of gait’. These are untimely interruptions in walking. The individual’s feet may become immobile despite the intention to walk. These episodes may last several seconds, which can be frustrating and lead to falls. One of the most effective treatments for freezing of gait for people with Parkinson’s is sensory cueing. 11 Cueing is where an external prompt is provided to the individual to help them to take a step and start walking again. Cues may be visual, auditory or vibrotactile. Various methods of visual cueing are simple and effective, such as having parallel lines drawn on the floor for the person to step over. More sophisticated solutions include a laser pointer incorporated in a walking stick that projects a dot on the floor ahead to walk towards. Other solutions include auditory cueing using a rhythmical beat to walk to such as a metronome, counting or music, and wearable vibrating devices. 12 There are several challenges in the delivery of cueing. The strategy often relies heavily on a therapist providing cueing in person with the individual being able to replicate this at home, which is not always feasible given it can require specific knowledge or equipment. Cueing is difficult to target, as there are different types of “cues” across visual, audio and vibrotactile modalities, where for each modality the positive effects on gait and balance vary widely between people due to the heterogeneity of their Parkinson’s. This means that a “one size fits all” solution is not possible, and cueing strategies must be personalised to the user. 13 The positive benefits on gait and balance from cueing can also wear off over time as the individual becomes accustomed to them. This is often referred to as habituation and means that any therapeutic input must be able to be easily adapted as the condition progresses in each individual. Many devices currently available deploy single modality sensory cueing methods and do not have the flexibility to adapt to changing needs. Therefore provision of effective and efficient sensory cueing treatments at scale to all people living with Parkinson’s who are experiencing freezing of gait poses a significant challenge. Augmented reality presents an opportunity to overcome the challenges of providing cueing to people living with Parkinson’s. Augmented reality involves wearing a headset that allows the user to see their real-life surroundings through a transparent screen on which is overlaid computer-generated interactive simulations. This allows users to engage with their environment with additional information. This study aims to investigate the feasibility of delivering gait and balance rehabilitation in people’s homes using augmented reality glasses. Methods Study design This was a prospective, single site, phase II, open label, uncontrolled feasibility study. The study was performed in accordance with the spirit and the letter of the declaration of Helsinki, the Principles of Good Clinical Practice, the protocol, and applicable local regulatory requirements and laws. This study received national and institutional review board approvals (IRAS Project Identification Number: 321744; Yorkshire and Humber Health Research Authority Committee 23/YH/0106) and was registered on ClinicalTrials.gov (NCT05794542). Setting This study was carried out predominantly in participant’s homes, where a home-based rehabilitation programme was delivered through augmented reality glasses. Baseline assessments, training in the use of the technology and follow-up assessments were carried out in the outpatient department at Chapel Allerton Hospital, Leeds, UK, which is part of Leeds Teaching Hospitals NHS Trust, a regional neurosciences rehabilitation unit. Participants We planned to recruit 30 participants whose walking and balance is affected by their Parkinson’s. Participants in the study were aged 18 years or older with a confirmed diagnosis of Parkinson’s and an ability to walk indoors with or without a walking aid (Hoehn and Yahr stages 2–4). For this feasibility study, participants were required to be under the care of a consultant physician or Parkinson’s specialist nurse within Leeds Teaching Hospitals NHS Trust. People with Parkinson’s were unable to participate if they had a skin condition on their head or face that prevented wearing the headset, had cognitive impairment meaning that they were unable to consent to take part, were unable to walk at any time, or had visual impairment meaning that they were unable to see the augmented reality information. People who had epilepsy that was not controlled by medication or who were experiencing hallucinations that affected their ability to interact with the augmented reality software were also unable to participate. Potential participants were identified by specialist doctors, nurses and physiotherapists. They were either known to these healthcare professionals or identified when they attended outpatient appointments and were provided with an information sheet containing a brief overview of the study. All participants were screened by the research physiotherapist to ensure that they met the eligibility criteria and were provided with a comprehensive information pack about the study. Study procedure Where possible, appointments were scheduled to try to make sure participants were assessed when they were experiencing their best functional ability (ON state). The ON state is used by people living with Parkinson’s to refer to a time when their medication is effective and their motor function is at its optimum. The OFF state refers to when their medication is wearing off and their motor symptoms may worsen. This time of day varies from person to person. Baseline assessment including informed consent procedure The initial appointments took place in the rehabilitation outpatient department at Chapel Allerton Hospital or in a participant’s home if required. Written, informed consent was given by all participants at this face-to-face appointment. Participation in the study was recorded in the participants’ electronic patient record. During the baseline assessment, participants’ demographic information, relevant medical history and medications were recorded, and patient-reported and clinician-scored outcome measures were collected. The Hoehn and Yahr stage was recorded for each participant. 14 This standardised staging scale is used to document the severity of Parkinson’s. Following training in the use of the technology and the prescription of an individualised augmented reality programme, each participant was provided with augmented reality glasses and a Wi-Fi router to use at home. Between baseline and follow-up assessments, participants received a telephone call from the research physiotherapist each week to check if there were any difficulties in carrying out their rehabilitation. Follow-up assessment On completion of 6 weeks of rehabilitation, each participant returned to the rehabilitation outpatient department and the follow-up outcome measures were completed. On conclusion of their involvement in the study, participants also completed a user satisfaction questionnaire comprising 16 questions; participants were also encouraged to provide free comments and suggestions for improvement. The Strolll technology was returned and prepared for the next participant. Outcome measures Participants were assessed using two clinician-scored measures and two self-reported measures: Timed-up-and-go (TUG) This is a clinician-scored test of gait and balance that is commonly used to examine functional mobility. The test measures the time in seconds that it takes a person to stand up from a chair, walk 3 metres, turn around, walk back to the chair and sit back down. 15 The TUG has been used extensively to measure gait and balance in people living with Parkinson's with lower scores indicating improved walking speed. 16 Lindop Parkinson’s Assessment Scale (LPAS) This is a standardised physical assessment of a person living with Parkinson’s ability to move in bed, sit, stand and walk. 17 Higher scores indicate greater physical ability. EuroQol-5D-5L (EQ-5D-5L) This is a well-established generic self-reported health-related quality of life measure validated for use with people with Parkinson’s. It provides a simple descriptive profile across the 5 dimensions of mobility, self-care, usual activities, pain and anxiety/depression, and a single index value for health status with higher scores indicating greater health-related quality of life. 18 Parkinson's Disease Questionnaire-39 (PDQ-39) The PDQ-39 is the most widely used condition-specific health-related quality of life rating scale for Parkinson’s. It is a 39-item self-report questionnaire, which assesses Parkinson’s-specific health-related quality of life across the 8 dimensions of mobility, activities of daily living, emotional well-being, stigma, social support, cognition, communication and bodily discomfort with lower scores indicating greater quality of life. 19 The overall PDQ-39 is summated in a single index, which is the sum of the dimensions divided by eight. Intervention This study used Strolll software on Magic Leap and Microsoft Hololens augmented reality glasses. Strolll supports independent rehabilitation, delivered in augmented reality by providing visual and audio cues though games in a single wearable device. The cue-assisted gait and balance exercises that underpin the games have been designed with people with Parkinson’s, physiotherapists and occupational therapists. The games are selected to form an exercise programme personalised to each user, aiming to maximise and maintain the positive effect of cueing on gait and balance over time. Strolll is software as a service, is CE marked and is a class 1 medical device with an ISO 13485 compliant QMS system. The hardware, Magic Leap and Microsoft Hololens augmented reality glasses, have the necessary electrical safety certificates and CE marks for consumer use. Following baseline assessment, participants were provided with an introduction to the glasses and the games including instructions, demonstrations and a trial of the device. Participants were shown how to charge and store the glasses between use. An individualised exercise programme was prescribed for each participant and seated, standing or walking games were selected based on each participant’s abilities. Programme selection considered participant safety as well as ensuring the tasks were sufficiently engaging and challenging to maintain participants’ motivation. Participants were taught how to select an appropriate area to do the games at home and how to set up the gaming area through the glasses. Participants were given advice regarding safety when using the glasses at home. Participants were asked to carry out daily games on the glasses. There were five games with the length of each game prescribed to last between 1 and 10 minutes. The prescribed daily activity time was between 5 and 50 minutes (most were prescribed between 10–15 minutes). Participants were asked to complete their programme as frequently as they felt able. Games were prescribed once a day, every day for 6 weeks but participants were advised that there were no expectations about how many times a week they completed the games. There was an option to repeat the games more than once in a day if the participant desired. Statistical Analysis Statistical analysis comprised parametric and non-parametric methods appropriate to the data. Analyses included descriptive statistics (frequencies, mean, median, SD and inter-quartile ranges) and paired t -tests to compare scores from baseline to follow-up. Statistical analyses were carried out in Microsoft Excel and IBM SPSS version 31.0.0.0 software packages with significance levels set at p < 0.05. The clinical significance of rehabilitation was evaluated using the effect size statistic, calculated as the mean change from baseline to follow-up divided by the standard deviation of the baseline score. 20 Larger effect sizes indicate greater impact of an intervention. The effect sizes were interpreted using Cohen’s criteria, where 0.20 is a small effect, 0.50 is moderate and 0.80 is large. 21 Results We recruited 30 participants to this feasibility study as planned in the protocol (Table 1 ). Twenty-eight participants completed the study and two withdrew. One person withdrew due to a change in home circumstances resulting in reduced time to participate in the study and one person with a medical diagnosis unrelated to Parkinson’s experienced a deterioration in that condition. There were no falls and no adverse events reported during the trial period for any participants. Data were available for 28 participants who completed 6 weeks of daily activities. Table 1 Participant characteristics Baseline characteristics Participants (n = 30) Age group of participants 46–55 years 1 56–65 years 9 66–75 12 76–85 7 86–95 1 Sex Male 23 Female 7 Ethnicity White English, Welsh, Scottish, Northern Irish or British 24 Other White background 2 Prefer not to say 4 Hoehn and Yahr stage II 18 III 8 IV 4 The clinician scored measures statistically significantly improved when compared to baseline (Table 2 ). The EQ-5D-5L (Table 2 ) and PDQ-39 (Table 3 ) did not show statistically significant changes. The TUG demonstrated a large effect size with the LPAS demonstrating a moderate effect size (Table 4 ). Of the self-report measures, the mobility scale of the PDQ-39 demonstrated a moderate effect size (Table 4 ). Table 2 Outcome measures Outcome Measure Initial Score Mean (SD) Follow up Score Mean (SD) t-test p -value (95% CI) Timed Up and Go 13.2 (12.1) 10.3 (9.5) < 0.001 (0.82–2.46) Lindop Assessment 27.5 (3.9) 28.6 (2.5) 0.004 (-1.58 – -0.268) EQ-5D-VAS 72.1 (16.0) 75.5 (15.6) 0.188 (-0.04–0.06) EQ-5D-5L 0.716 (0.188) 0.707 (0.235) 0.359 (-8.81–3.45) Table 3 Parkinson’s Disease Questionaire-39 outcomes PDQ-39 Domain Initial Score Mean (SD) Follow up Score Mean (SD) t-test p -value (95% CI) Mobility 13.2 (12.1) 10.3 (9.5) 0.793 (-5.41–7.02) Activities of daily living 27.5 (3.9) 28.6 (2.5) 0.939 (-4.62–4.29) Emotional well-being 24.1 (17.5) 19.3 (13.8) 0.547 (-4.38–2.38) Stigma 72.1 (16.0) 75.5 (15.6) 0.463 (-2.80–5.96) Social support 11.3 (16.8) 5.4 (10.0) 0.201 (-1.60–7.10) Cognition 28.2 (18.6) 25.0 (19.1) 0.552 (-3.03–5.53) Communication 23.0 (25.3) 18.6 (20.6) 0.777 (-3.98–5.32) Bodily discomfort 32.8 (21.0) 28.5 (19.5) 0.454 (-3.99–8.65) Single index 24.1 (17.5) 19.3 (13.8) 0.261 (-1.81–6.38) Table 4 Effect sizes of outcome measures Outcome Measure Effect size 95% Confidence interval Lower Upper Timed Up and Go 0.845 0.371 1.307 Lindop Assessment -0.557 -0.959 -0.146 EQ-5D-VAS -0.180 -0.574 0.217 EQ-5D-5L 0.073 -0.320 0.465 PDQ-39 Domains Mobility 0.530 -0.340 0.445 Activities of daily living -0.015 -0.407 0.377 Emotional well-being -0.122 -0.514 0.273 Stigma 0.149 -0.247 0.542 Social support 0.263 -0.139 0.659 Cognition 0.121 -0.274 0.513 Communication 0.059 -0.334 0.451 Bodily discomfort 0.152 -0.244 0.545 Single index 0.226 -0.166 0.613 Twenty-five participants completed a feedback questionnaire and 21 provided free text feedback (Table 5 ). Three participants did not complete a questionnaire. Most participants found the glasses satisfactory and would recommend them to another person living with Parkinson’s. We identified five themes from the written feedback (Box). Table 5 Patient Feedback Questionnaire Question Strongly Agree Agree Neutral Disagree Strongly Disagree 1. The glasses were easy to put on 20 4 1 2. I felt comfortable wearing the glasses 17 5 2 1 3. I felt safe while using the glasses 21 4 4. I felt the games encouraged me to exercise 19 5 1 5. The instructions on the glasses were understandable 19 2 4 6. The exercises were fun 19 5 1 7. The exercises were motivating 17 7 1 8. The exercises were varied 15 6 3 9. The exercises were boring 12 6 3 3 1 10. The exercises were frustrating 7 6 8 1 3 11. The glasses took too long to set up once I was home 6 8 6 4 1 12. I felt excited about using the glasses 8 11 5 1 13. I felt scared about using the glasses 19 4 1 1 14. I would consider using CUE X on the glasses for my future rehabilitation 17 6 2 15. I would be willing to take part in future research about CUE X 22 1 1 16. I would recommend using CUE X exercises for other people with Parkinson’s disease 18 5 1 Therapeutic recognition and physical benefits The feedback we received was largely positive regarding the physical benefits of the games as exercise. Participants felt that the games were challenging as a form of exercise with cardiovascular and balance elements. System performance and usability issues There was substantial feedback about the technical aspects of using a new piece of technology. There were reports of glitches when using the game and difficulty with setting up the games at home which required external support from family members, the research team or Strolll technical support. The feedback suggested that once set up was complete the usability improved. The set up difficulties and glitches during game play led to frustration amongst participants. As the study progresses, and glitches were resolved through software updates, feedback on these issues improved. Participants also mentioned issues using the technology in their home environment. Some participants noted that a substantial space was required, with others reporting they were unable to play certain games due to space limitations. Engagement evolution and motivation The feedback indicated that participants expressed initial interest and excitement in using the technology. For some participants this initial excitement wore off and the games became repetitive, with some participants suggesting that there needed to be more variety of games. Participants commented that the games were ‘fun’ and overall, the feedback conveyed enjoyment despite occasional frustrations with the technology. Motivation was mentioned frequently in comments, with some participants highlighting that they felt the games themselves to be motivating. Others noted that the involvement of the research physiotherapist was a motivating factor. Individual Needs and Personalisation The games were tailored to individuals in terms of length of time played and game play difficulty. Feedback included participants expressing they would have liked even further personalisation, for example, different playing heights for some games, and more access to their game data. One participant suggested a voice recording in the game to include their name for further motivational support. Support infrastructure and implementation There were a lot of comments regarding the amount of support from others that was required, especially in the initial set up. This relates back to the initial difficulties experienced in set up and game play. There were frequent, positive references made to the physiotherapist and the support given during set-up, over the phone and through home visits. Discussion This was the first use of augmented reality-delivered rehabilitation in the UK’s National Health Service and demonstrated that Strolll software can be deployed for independent use to deliver rehabilitation at home to people living with Parkinson’s. Through face-to-face training, and a six-week programme of remote intervention, we were able to show that the use of augmented reality to deliver rehabilitation in people with Parkinson’s is feasible with an early signal suggesting that participants’ mobility improved through the use of the technology. Participants noted that the technology was generally acceptable to use and provided motivation to engage in rehabilitation exercise. Comments relating to difficulties in setting up the technology at home were fed back to Strolll who instituted a series of improvements in the set up process which resulted in improved feedback from later participants. There are a number of limitations to this study. This was a non-randomised study carried out in a single centre. Funding has now been obtained from the UK’s National Institute for Health and Care Research to recruit participants to a multi-centre randomised controlled trial. There were more male than female participants in the study than would be expected from the population of people living with Parkinson’s and most participants were white. The randomised controlled trial will be designed to more accurately reflect the sex and ethnicity of people living in the UK with Parkinson’s. An important objective of this study was to monitor the safety of the participants and ensure that risk was minimised through appropriate game selection, advice and education. A systematic review has reported technology-enhanced physiotherapy for gait and balance training to be safe for use at home in people with Parkinson’s. 22 Our study had no adverse events reported for the entirety of the participants’ involvement with the intervention. Conclusion We have identified that augmented reality-delivered rehabilitation is a feasible, safe and potentially effective treatment for the symptoms associated with Parkinson’s. Augmented reality provides a convenient, flexible option for some people and may increase accessibility to rehabilitation which may reduce the burden of attending appointments due to no travel time and cost. Further research is underway to determine the therapeutic benefits as well as assessing the health economics of using this technology compared with usual rehabilitation in the NHS. Declarations Acknowledgements The authors would like to thank the participants in this study who volunteered to engage with a novel intervention. Availability of data The anonymised data supporting the conclusions of this study are available from the corresponding author upon reasonable request. Funding This project was supported by funding from the Engineering and Physical Sciences Research Council (EP/S019219/1), the NHS Digital Unified Tech Fund (XR/AR UTF ANON-5DCB-YXZX-1) and the University of Leeds Institutional Translational Funding: Pathfinder & Feasibility Fund. RJOC is supported by the NIHR HealthTech Research Centre in Long Term Conditions (D4D). The views expressed in this publication are those of the authors and not necessarily those of NIHR or the Department of Health and Social Care. Competing interests The authors declare that they have no conflicts of interest. Author contributions CG and RJOC contributed to study design. AW and CB assisted with participant recruitment. AW, CB and AS assisted with data collection. CW, AS and RJOC conducted the data analysis and interpretation. 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Effect sizes for interpreting changes in health status. Med.Care 27 , S178–S189 (1989). Cohen, J. A power primer. Psychological Bulletin 112 , 155–159 (1992). Radder, D. L. M. et al. Physiotherapy in Parkinson's Disease: A Meta-Analysis of Present Treatment Modalities. Neurorehabilitation and neural repair 34 , 871–880 (2020). https://doi.org/10.1177/1545968320952799 Box Box is available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Box.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9117546","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605840254,"identity":"f4ee4354-a1bb-452f-8f0e-91f61190049a","order_by":0,"name":"Caroline Gill","email":"","orcid":"","institution":"Leeds Teaching Hospital NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Gill","suffix":""},{"id":605840255,"identity":"452b56f6-b4d9-4f0d-8036-9b4ffbdec83d","order_by":1,"name":"Alexandra Whelan","email":"","orcid":"","institution":"Leeds Teaching Hospital NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Whelan","suffix":""},{"id":605840256,"identity":"cc2961ae-6d99-4381-a662-03d2ec29fbc7","order_by":2,"name":"Cheryl Bell","email":"","orcid":"","institution":"Leeds Teaching Hospital NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Cheryl","middleName":"","lastName":"Bell","suffix":""},{"id":605840257,"identity":"c3422add-06cf-423e-90d7-d45993c57ed4","order_by":3,"name":"Ansa Sunil","email":"","orcid":"","institution":"University of Leeds","correspondingAuthor":false,"prefix":"","firstName":"Ansa","middleName":"","lastName":"Sunil","suffix":""},{"id":605840258,"identity":"02a2abd1-727c-4ee7-bd5d-0f36edc9ee48","order_by":4,"name":"Rory J O'Connor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIie2RMQrCMBSGX4g4ibsI9QqvBLRiqVepBHTp4OhmpeDUA1T0EB4hJaBj14weoeBScNDYguAQ6eiQjxDeP3wkPw/AYvlD5jG5QekFTSrX+hLNjCYFBYQk83gdSIYtFdoL8zrQXnsFhDMZJpe7j77TLwQpK5DM3KVR2PR04ccIl2ygQjpIQY5Niu5dK4uzihiNUOoBYAggfZPCvhQPn9tzIejjl+LGnbeSN4quFurTfb9i/BjKrsgz4AzVkpMUuXtQi/00xZWxPl6T3a2EwEHFJVSbYNQvpFTVZubGJod+FvGBxD+2YrFYLJY2vABU7lSitLkWZQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-4643-9794","institution":"University of Leeds","correspondingAuthor":true,"prefix":"","firstName":"Rory","middleName":"J","lastName":"O'Connor","suffix":""}],"badges":[],"createdAt":"2026-03-13 18:55:12","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9117546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9117546/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104835079,"identity":"f2ef9242-e945-44a2-b37e-76aae4560959","added_by":"auto","created_at":"2026-03-17 17:39:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":960889,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117546/v1/2b570527-392c-415d-8c3f-409108bb82fd.pdf"},{"id":104828864,"identity":"80493553-6426-41dd-a55a-ee230cbf300f","added_by":"auto","created_at":"2026-03-17 16:07:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19144,"visible":true,"origin":"","legend":"","description":"","filename":"Box.docx","url":"https://assets-eu.researchsquare.com/files/rs-9117546/v1/b8be026b021df3845f93ce85.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAugmented reality rehabilitation at home for adults with Parkinson's disease: a feasibility study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eParkinson\u0026rsquo;s disease is a progressive neurological condition that profoundly affects a person\u0026rsquo;s functioning.\u003csup\u003e1\u003c/sup\u003e It is the most rapidly growing neurological condition globally and affects more than 153,000 people in the UK.\u003csup\u003e2\u003c/sup\u003e There is a rising prevalence with age, and projections indicate that the number of people living with Parkinson\u0026rsquo;s will double in the next two decades, escalating the demands on health and social care services.\u003csup\u003e3\u003c/sup\u003e Each year in the UK, over 17,300 people are newly diagnosed with Parkinson\u0026rsquo;s. Men are 1.5 times more likely to develop Parkinson\u0026rsquo;s than women.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are three main characteristic clinical features of Parkinson\u0026rsquo;s \u0026ndash; tremor, bradykinesia and rigidity. These motor impairments affect balance and gait, particularly walking speed, and frequently lead to falls.\u003csup\u003e1\u003c/sup\u003e Many people with Parkinson\u0026rsquo;s experience cognitive impairment, sleep disturbance, anxiety or depression, further complicating people\u0026rsquo;s experience with the condition.\u003c/p\u003e \u003cp\u003eThe UK\u0026rsquo;s Department of Health and Social Care guidelines for the adult population recommend 150 minutes of moderate intensity physical activity, equivalent to 30 minutes per day for 5 days a week, or 75 minutes of vigorous intensity physical activity for everyone each week.\u003csup\u003e5\u003c/sup\u003e Exercise can improve physical health as well as improve sleep quality, mental health and well-being. This is no different for people living with Parkinson\u0026rsquo;s. Indeed, people living with Parkinson\u0026rsquo;s are encouraged to engage in a daily exercise programme to maintain their mobility, independence, and quality of life. Studies have shown that exercise can be a neuroprotective mechanism in Parkinson\u0026rsquo;s and improve symptoms.\u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, it can be difficult for people with Parkinson\u0026rsquo;s to perform exercises because of their motor impairments. In addition, as their gait and balance deteriorate, their fear of falls can increase, and participating in exercise groups outside the home or maintaining engagement in a generic home exercise programme becomes more difficult. All of these factors can lead to reduced function, independence and quality of life.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe National Institute for Health and Care Excellence (NICE) in the UK recommends offering Parkinson's-specific therapy to people who are experiencing balance or motor impairments.\u003csup\u003e9\u003c/sup\u003e These therapies are most frequently delivered in specialised clinics, usually in hospital outpatient departments. Attending hospital appointments can be difficult and inconvenient for many people, particularly for those whose mobility is already impaired.\u003csup\u003e10\u003c/sup\u003e Home-based community services are costly, often stretched and not always available when needed. Importantly, therapy, whether during a clinic or a home appointment, will not be accessible to a person with Parkinson\u0026rsquo;s experiencing an \u0026ldquo;off\u0026rdquo; period, when the effect of medication has worn off. As Parkinson\u0026rsquo;s disease continues to rise in prevalence, it is imperative that therapy services adapt to meet the increasing and evolving demands.\u003c/p\u003e \u003cp\u003eAs Parkinson\u0026rsquo;s progresses, people may experience episodes of \u0026lsquo;freezing of gait\u0026rsquo;. These are untimely interruptions in walking. The individual\u0026rsquo;s feet may become immobile despite the intention to walk. These episodes may last several seconds, which can be frustrating and lead to falls. One of the most effective treatments for freezing of gait for people with Parkinson\u0026rsquo;s is sensory cueing.\u003csup\u003e11\u003c/sup\u003e Cueing is where an external prompt is provided to the individual to help them to take a step and start walking again. Cues may be visual, auditory or vibrotactile. Various methods of visual cueing are simple and effective, such as having parallel lines drawn on the floor for the person to step over. More sophisticated solutions include a laser pointer incorporated in a walking stick that projects a dot on the floor ahead to walk towards. Other solutions include auditory cueing using a rhythmical beat to walk to such as a metronome, counting or music, and wearable vibrating devices.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are several challenges in the delivery of cueing. The strategy often relies heavily on a therapist providing cueing in person with the individual being able to replicate this at home, which is not always feasible given it can require specific knowledge or equipment. Cueing is difficult to target, as there are different types of \u0026ldquo;cues\u0026rdquo; across visual, audio and vibrotactile modalities, where for each modality the positive effects on gait and balance vary widely between people due to the heterogeneity of their Parkinson\u0026rsquo;s. This means that a \u0026ldquo;one size fits all\u0026rdquo; solution is not possible, and cueing strategies must be personalised to the user.\u003csup\u003e13\u003c/sup\u003e The positive benefits on gait and balance from cueing can also wear off over time as the individual becomes accustomed to them. This is often referred to as habituation and means that any therapeutic input must be able to be easily adapted as the condition progresses in each individual. Many devices currently available deploy single modality sensory cueing methods and do not have the flexibility to adapt to changing needs. Therefore provision of effective and efficient sensory cueing treatments at scale to all people living with Parkinson\u0026rsquo;s who are experiencing freezing of gait poses a significant challenge.\u003c/p\u003e \u003cp\u003eAugmented reality presents an opportunity to overcome the challenges of providing cueing to people living with Parkinson\u0026rsquo;s. Augmented reality involves wearing a headset that allows the user to see their real-life surroundings through a transparent screen on which is overlaid computer-generated interactive simulations. This allows users to engage with their environment with additional information. This study aims to investigate the feasibility of delivering gait and balance rehabilitation in people\u0026rsquo;s homes using augmented reality glasses.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a prospective, single site, phase II, open label, uncontrolled feasibility study. The study was performed in accordance with the spirit and the letter of the declaration of Helsinki, the Principles of Good Clinical Practice, the protocol, and applicable local regulatory requirements and laws. This study received national and institutional review board approvals (IRAS Project Identification Number: 321744; Yorkshire and Humber Health Research Authority Committee 23/YH/0106) and was registered on ClinicalTrials.gov (NCT05794542).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003e This study was carried out predominantly in participant\u0026rsquo;s homes, where a home-based rehabilitation programme was delivered through augmented reality glasses. Baseline assessments, training in the use of the technology and follow-up assessments were carried out in the outpatient department at Chapel Allerton Hospital, Leeds, UK, which is part of Leeds Teaching Hospitals NHS Trust, a regional neurosciences rehabilitation unit.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003e We planned to recruit 30 participants whose walking and balance is affected by their Parkinson\u0026rsquo;s. Participants in the study were aged 18 years or older with a confirmed diagnosis of Parkinson\u0026rsquo;s and an ability to walk indoors with or without a walking aid (Hoehn and Yahr stages 2\u0026ndash;4). For this feasibility study, participants were required to be under the care of a consultant physician or Parkinson\u0026rsquo;s specialist nurse within Leeds Teaching Hospitals NHS Trust.\u003c/p\u003e \u003cp\u003ePeople with Parkinson\u0026rsquo;s were unable to participate if they had a skin condition on their head or face that prevented wearing the headset, had cognitive impairment meaning that they were unable to consent to take part, were unable to walk at any time, or had visual impairment meaning that they were unable to see the augmented reality information. People who had epilepsy that was not controlled by medication or who were experiencing hallucinations that affected their ability to interact with the augmented reality software were also unable to participate.\u003c/p\u003e \u003cp\u003ePotential participants were identified by specialist doctors, nurses and physiotherapists. They were either known to these healthcare professionals or identified when they attended outpatient appointments and were provided with an information sheet containing a brief overview of the study. All participants were screened by the research physiotherapist to ensure that they met the eligibility criteria and were provided with a comprehensive information pack about the study.\u003c/p\u003e\n\u003ch3\u003eStudy procedure\u003c/h3\u003e\n\u003cp\u003eWhere possible, appointments were scheduled to try to make sure participants were assessed when they were experiencing their best functional ability (ON state). The ON state is used by people living with Parkinson\u0026rsquo;s to refer to a time when their medication is effective and their motor function is at its optimum. The OFF state refers to when their medication is wearing off and their motor symptoms may worsen. This time of day varies from person to person.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBaseline assessment including informed consent procedure\u003c/strong\u003e \u003cp\u003eThe initial appointments took place in the rehabilitation outpatient department at Chapel Allerton Hospital or in a participant\u0026rsquo;s home if required. Written, informed consent was given by all participants at this face-to-face appointment. Participation in the study was recorded in the participants\u0026rsquo; electronic patient record.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e During the baseline assessment, participants\u0026rsquo; demographic information, relevant medical history and medications were recorded, and patient-reported and clinician-scored outcome measures were collected. The Hoehn and Yahr stage was recorded for each participant.\u003csup\u003e14\u003c/sup\u003e This standardised staging scale is used to document the severity of Parkinson\u0026rsquo;s.\u003c/p\u003e \u003cp\u003eFollowing training in the use of the technology and the prescription of an individualised augmented reality programme, each participant was provided with augmented reality glasses and a Wi-Fi router to use at home. Between baseline and follow-up assessments, participants received a telephone call from the research physiotherapist each week to check if there were any difficulties in carrying out their rehabilitation.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFollow-up assessment\u003c/strong\u003e \u003cp\u003eOn completion of 6 weeks of rehabilitation, each participant returned to the rehabilitation outpatient department and the follow-up outcome measures were completed. On conclusion of their involvement in the study, participants also completed a user satisfaction questionnaire comprising 16 questions; participants were also encouraged to provide free comments and suggestions for improvement. The Strolll technology was returned and prepared for the next participant.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eParticipants were assessed using two clinician-scored measures and two self-reported measures:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTimed-up-and-go (TUG)\u003c/strong\u003e \u003cp\u003eThis is a clinician-scored test of gait and balance that is commonly used to examine functional mobility. The test measures the time in seconds that it takes a person to stand up from a chair, walk 3 metres, turn around, walk back to the chair and sit back down.\u003csup\u003e15\u003c/sup\u003e The TUG has been used extensively to measure gait and balance in people living with Parkinson's with lower scores indicating improved walking speed.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLindop Parkinson\u0026rsquo;s Assessment Scale (LPAS)\u003c/strong\u003e \u003cp\u003eThis is a standardised physical assessment of a person living with Parkinson\u0026rsquo;s ability to move in bed, sit, stand and walk.\u003csup\u003e17\u003c/sup\u003e Higher scores indicate greater physical ability.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEuroQol-5D-5L (EQ-5D-5L)\u003c/strong\u003e \u003cp\u003eThis is a well-established generic self-reported health-related quality of life measure validated for use with people with Parkinson\u0026rsquo;s. It provides a simple descriptive profile across the 5 dimensions of mobility, self-care, usual activities, pain and anxiety/depression, and a single index value for health status with higher scores indicating greater health-related quality of life.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParkinson's Disease Questionnaire-39 (PDQ-39)\u003c/strong\u003e \u003cp\u003eThe PDQ-39 is the most widely used condition-specific health-related quality of life rating scale for Parkinson\u0026rsquo;s. It is a 39-item self-report questionnaire, which assesses Parkinson\u0026rsquo;s-specific health-related quality of life across the 8 dimensions of mobility, activities of daily living, emotional well-being, stigma, social support, cognition, communication and bodily discomfort with lower scores indicating greater quality of life.\u003csup\u003e19\u003c/sup\u003e The overall PDQ-39 is summated in a single index, which is the sum of the dimensions divided by eight.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThis study used Strolll software on Magic Leap and Microsoft Hololens augmented reality glasses. Strolll supports independent rehabilitation, delivered in augmented reality by providing visual and audio cues though games in a single wearable device. The cue-assisted gait and balance exercises that underpin the games have been designed with people with Parkinson\u0026rsquo;s, physiotherapists and occupational therapists. The games are selected to form an exercise programme personalised to each user, aiming to maximise and maintain the positive effect of cueing on gait and balance over time. Strolll is software as a service, is CE marked and is a class 1 medical device with an ISO 13485 compliant QMS system. The hardware, Magic Leap and Microsoft Hololens augmented reality glasses, have the necessary electrical safety certificates and CE marks for consumer use.\u003c/p\u003e \u003cp\u003eFollowing baseline assessment, participants were provided with an introduction to the glasses and the games including instructions, demonstrations and a trial of the device. Participants were shown how to charge and store the glasses between use. An individualised exercise programme was prescribed for each participant and seated, standing or walking games were selected based on each participant\u0026rsquo;s abilities. Programme selection considered participant safety as well as ensuring the tasks were sufficiently engaging and challenging to maintain participants\u0026rsquo; motivation. Participants were taught how to select an appropriate area to do the games at home and how to set up the gaming area through the glasses. Participants were given advice regarding safety when using the glasses at home.\u003c/p\u003e \u003cp\u003e Participants were asked to carry out daily games on the glasses. There were five games with the length of each game prescribed to last between 1 and 10 minutes. The prescribed daily activity time was between 5 and 50 minutes (most were prescribed between 10\u0026ndash;15 minutes). Participants were asked to complete their programme as frequently as they felt able. Games were prescribed once a day, every day for 6 weeks but participants were advised that there were no expectations about how many times a week they completed the games. There was an option to repeat the games more than once in a day if the participant desired.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis comprised parametric and non-parametric methods appropriate to the data. Analyses included descriptive statistics (frequencies, mean, median, SD and inter-quartile ranges) and paired \u003cem\u003et\u003c/em\u003e-tests to compare scores from baseline to follow-up. Statistical analyses were carried out in Microsoft Excel and IBM SPSS version 31.0.0.0 software packages with significance levels set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eThe clinical significance of rehabilitation was evaluated using the effect size statistic, calculated as the mean change from baseline to follow-up divided by the standard deviation of the baseline score.\u003csup\u003e20\u003c/sup\u003e Larger effect sizes indicate greater impact of an intervention. The effect sizes were interpreted using Cohen\u0026rsquo;s criteria, where 0.20 is a small effect, 0.50 is moderate and 0.80 is large.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe recruited 30 participants to this feasibility study as planned in the protocol (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Twenty-eight participants completed the study and two withdrew. One person withdrew due to a change in home circumstances resulting in reduced time to participate in the study and one person with a medical diagnosis unrelated to Parkinson\u0026rsquo;s experienced a deterioration in that condition. There were no falls and no adverse events reported during the trial period for any participants. Data were available for 28 participants who completed 6 weeks of daily activities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge group of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u0026ndash;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u0026ndash;65\u0026nbsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u0026ndash;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u0026ndash;95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite English, Welsh, Scottish, Northern Irish or British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther White background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHoehn and Yahr stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe clinician scored measures statistically significantly improved when compared to baseline (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The EQ-5D-5L (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and PDQ-39 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) did not show statistically significant changes. The TUG demonstrated a large effect size with the LPAS demonstrating a moderate effect size (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Of the self-report measures, the mobility scale of the PDQ-39 demonstrated a moderate effect size (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow up Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-test\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimed Up and Go\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.2 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.3 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 (0.82\u0026ndash;2.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLindop Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.5 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.6 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004 (-1.58 \u0026ndash; -0.268)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72.1 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.5 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.188 (-0.04\u0026ndash;0.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.716 (0.188)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.707 (0.235)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.359 (-8.81\u0026ndash;3.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParkinson\u0026rsquo;s Disease Questionaire-39 outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePDQ-39 Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow up Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-test\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.2 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.3 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.793 (-5.41\u0026ndash;7.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.5 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.6 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.939 (-4.62\u0026ndash;4.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.3 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.547 (-4.38\u0026ndash;2.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72.1 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.5 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.463 (-2.80\u0026ndash;5.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.3 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.4 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.201 (-1.60\u0026ndash;7.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.2 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.552 (-3.03\u0026ndash;5.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.0 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.6 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.777 (-3.98\u0026ndash;5.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBodily discomfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.8 (21.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.5 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.454 (-3.99\u0026ndash;8.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.3 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e0.261 (-1.81\u0026ndash;6.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect sizes of outcome measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOutcome Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95% Confidence interval\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimed Up and Go\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLindop Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePDQ-39 Domains\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.334\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.451\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBodily discomfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwenty-five participants completed a feedback questionnaire and 21 provided free text feedback (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Three participants did not complete a questionnaire. Most participants found the glasses satisfactory and would recommend them to another person living with Parkinson\u0026rsquo;s. We identified five themes from the written feedback (Box).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Feedback Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly Agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStrongly Disagree\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. The glasses were easy to put on\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. I felt comfortable wearing the glasses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. I felt safe while using the glasses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. I felt the games encouraged me to exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. The instructions on the glasses were understandable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. The exercises were fun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. The exercises were motivating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. The exercises were varied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. The exercises were boring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. The exercises were frustrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. The glasses took too long to set up once I was home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. I felt excited about using the glasses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. I felt scared about using the glasses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. I would consider using CUE X on the glasses for my future rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. I would be willing to take part in future research about CUE X\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. I would recommend using CUE X exercises for other people with Parkinson\u0026rsquo;s disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTherapeutic recognition and physical benefits\u003c/h2\u003e \u003cp\u003eThe feedback we received was largely positive regarding the physical benefits of the games as exercise. Participants felt that the games were challenging as a form of exercise with cardiovascular and balance elements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSystem performance and usability issues\u003c/h2\u003e \u003cp\u003eThere was substantial feedback about the technical aspects of using a new piece of technology. There were reports of glitches when using the game and difficulty with setting up the games at home which required external support from family members, the research team or Strolll technical support. The feedback suggested that once set up was complete the usability improved. The set up difficulties and glitches during game play led to frustration amongst participants. As the study progresses, and glitches were resolved through software updates, feedback on these issues improved. Participants also mentioned issues using the technology in their home environment. Some participants noted that a substantial space was required, with others reporting they were unable to play certain games due to space limitations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEngagement evolution and motivation\u003c/h2\u003e \u003cp\u003eThe feedback indicated that participants expressed initial interest and excitement in using the technology. For some participants this initial excitement wore off and the games became repetitive, with some participants suggesting that there needed to be more variety of games. Participants commented that the games were \u0026lsquo;fun\u0026rsquo; and overall, the feedback conveyed enjoyment despite occasional frustrations with the technology.\u003c/p\u003e \u003cp\u003e Motivation was mentioned frequently in comments, with some participants highlighting that they felt the games themselves to be motivating. Others noted that the involvement of the research physiotherapist was a motivating factor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIndividual Needs and Personalisation\u003c/h2\u003e \u003cp\u003eThe games were tailored to individuals in terms of length of time played and game play difficulty. Feedback included participants expressing they would have liked even further personalisation, for example, different playing heights for some games, and more access to their game data. One participant suggested a voice recording in the game to include their name for further motivational support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSupport infrastructure and implementation\u003c/h2\u003e \u003cp\u003eThere were a lot of comments regarding the amount of support from others that was required, especially in the initial set up. This relates back to the initial difficulties experienced in set up and game play. There were frequent, positive references made to the physiotherapist and the support given during set-up, over the phone and through home visits.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis was the first use of augmented reality-delivered rehabilitation in the UK\u0026rsquo;s National Health Service and demonstrated that Strolll software can be deployed for independent use to deliver rehabilitation at home to people living with Parkinson\u0026rsquo;s. Through face-to-face training, and a six-week programme of remote intervention, we were able to show that the use of augmented reality to deliver rehabilitation in people with Parkinson\u0026rsquo;s is feasible with an early signal suggesting that participants\u0026rsquo; mobility improved through the use of the technology.\u003c/p\u003e \u003cp\u003eParticipants noted that the technology was generally acceptable to use and provided motivation to engage in rehabilitation exercise. Comments relating to difficulties in setting up the technology at home were fed back to Strolll who instituted a series of improvements in the set up process which resulted in improved feedback from later participants.\u003c/p\u003e \u003cp\u003eThere are a number of limitations to this study. This was a non-randomised study carried out in a single centre. Funding has now been obtained from the UK\u0026rsquo;s National Institute for Health and Care Research to recruit participants to a multi-centre randomised controlled trial. There were more male than female participants in the study than would be expected from the population of people living with Parkinson\u0026rsquo;s and most participants were white. The randomised controlled trial will be designed to more accurately reflect the sex and ethnicity of people living in the UK with Parkinson\u0026rsquo;s.\u003c/p\u003e \u003cp\u003eAn important objective of this study was to monitor the safety of the participants and ensure that risk was minimised through appropriate game selection, advice and education. A systematic review has reported technology-enhanced physiotherapy for gait and balance training to be safe for use at home in people with Parkinson\u0026rsquo;s.\u003csup\u003e22\u003c/sup\u003e Our study had no adverse events reported for the entirety of the participants\u0026rsquo; involvement with the intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe have identified that augmented reality-delivered rehabilitation is a feasible, safe and potentially effective treatment for the symptoms associated with Parkinson\u0026rsquo;s. Augmented reality provides a convenient, flexible option for some people and may increase accessibility to rehabilitation which may reduce the burden of attending appointments due to no travel time and cost. Further research is underway to determine the therapeutic benefits as well as assessing the health economics of using this technology compared with usual rehabilitation in the NHS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the participants in this study who volunteered to engage with a novel intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anonymised data supporting the conclusions of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported by funding from the Engineering and Physical Sciences Research Council (EP/S019219/1), the NHS Digital Unified Tech Fund (XR/AR UTF ANON-5DCB-YXZX-1) and the University of Leeds Institutional Translational Funding: Pathfinder \u0026amp; Feasibility Fund. RJOC is supported by the NIHR HealthTech Research Centre in Long Term Conditions (D4D). The views expressed in this publication are those of the authors and not necessarily those of NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCG and RJOC contributed to study design. AW and CB assisted with participant recruitment. AW, CB and AS assisted with data collection. CW, AS and RJOC conducted the data analysis and interpretation. CW and RJOC prepared the manuscript. All authors reviewed, provided comments and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eO\u0026apos;Connor, R. J. \u0026amp; Kini, M. U. Non-pharmacological and non-surgical interventions for tremor: A systematic review. \u003cem\u003eParkinsonism \u0026amp; Related Disorders\u003c/em\u003e \u003cstrong\u003e17\u003c/strong\u003e, 509\u0026ndash;515 (2011). \u003c/li\u003e\n\u003cli\u003eLees, A. J., Hardy, J. \u0026amp; Revesz, T. Parkinson\u0026apos;s disease. \u003cem\u003eLancet\u003c/em\u003e \u003cstrong\u003e373\u003c/strong\u003e, 2055\u0026ndash;2066 (2009). \u003c/li\u003e\n\u003cli\u003eNational Audit Office. (ed Office of the Comptroller and Auditor General) (2011).\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Parkinson\u0026apos;s disease Quality Standard (QS164). (2018).\u003c/li\u003e\n\u003cli\u003eChief Medical Officers. UK Chief Medical Officers\u0026apos; Physical Activity Guidelines. (London, 2019).\u003c/li\u003e\n\u003cli\u003eMitchell, A. K., Bliss, R. R. \u0026amp; Church, F. C. Exercise, Neuroprotective Exerkines, and Parkinson\u0026apos;s Disease: A Narrative Review. \u003cem\u003eBiomolecules\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e (2024). https://doi.org/10.3390/biom14101241\u003c/li\u003e\n\u003cli\u003eWilson, A. C., Pountney, D. L. \u0026amp; Khoo, T. K. Therapeutic Mechanisms of Exercise in Parkinson\u0026apos;s Disease. \u003cem\u003eInt J Mol Sci\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e (2025). https://doi.org/10.3390/ijms26104860\u003c/li\u003e\n\u003cli\u003eBernard, S., Aspinal, F., Gridley, K. \u0026amp; Parker, G. Integrated Services for People with Long-term Neurological Conditions: Evaluation of the impact of the National Service Framework. (Social Policy Research Unit, University of York, York, 2010).\u003c/li\u003e\n\u003cli\u003eNational Collaborating Centre for Chronic Conditions. Parkinson\u0026rsquo;s disease: national clinical guideline for diagnosis and management in primary and secondary care., (Royal College of Physicians, London, 2006).\u003c/li\u003e\n\u003cli\u003eClark, W. E., Sivan, M. \u0026amp; O\u0026apos;Connor, R. J. Evaluating the use of robotic and virtual reality rehabilitation technologies to improve function in stroke survivors: A narrative review. \u003cem\u003eJournal of Rehabilitation and Assistive Technologies Engineering\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 2055668319863557 (2019). https://doi.org/10.1177/2055668319863557\u003c/li\u003e\n\u003cli\u003eCui, C. K. \u0026amp; Lewis, S. J. G. Future Therapeutic Strategies for Freezing of Gait in Parkinson\u0026apos;s Disease. \u003cem\u003eFront Hum Neurosci\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 741918 (2021). https://doi.org/10.3389/fnhum.2021.741918\u003c/li\u003e\n\u003cli\u003eGinis, P., Nackaerts, E., Nieuwboer, A. \u0026amp; Heremans, E. Cueing for people with Parkinson\u0026apos;s disease with freezing of gait: A narrative review of the state-of-the-art and novel perspectives. \u003cem\u003eAnnals of Physical and Rehabilitation Medicine\u003c/em\u003e \u003cstrong\u003e61\u003c/strong\u003e, 407\u0026ndash;413 (2018). https://doi.org/https://doi.org/10.1016/j.rehab.2017.08.002\u003c/li\u003e\n\u003cli\u003eNieuwboer, A. Cueing effects in Parkinson\u0026apos;s disease: Benefits and drawbacks. \u003cem\u003eAnnals of Physical and Rehabilitation Medicine\u003c/em\u003e \u003cstrong\u003e58\u003c/strong\u003e, e70\u0026ndash;e71 (2015). https://doi.org/https://doi.org/10.1016/j.rehab.2015.07.173\u003c/li\u003e\n\u003cli\u003eGoetz, C. G.\u003cem\u003e et al.\u003c/em\u003e Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: status and recommendations. \u003cem\u003eMov Disord\u003c/em\u003e \u003cstrong\u003e19\u003c/strong\u003e, 1020\u0026ndash;1028 (2004). https://doi.org/10.1002/mds.20213\u003c/li\u003e\n\u003cli\u003ePodsiadlo, D. \u0026amp; Richardson, S. The timed \u0026quot;Up \u0026amp; Go\u0026quot;: a test of basic functional mobility for frail elderly persons. \u003cem\u003eJournal of the American Geriatrics Society\u003c/em\u003e \u003cstrong\u003e39\u003c/strong\u003e, 142\u0026ndash;148 (1991). \u003c/li\u003e\n\u003cli\u003eNocera, J. R.\u003cem\u003e et al.\u003c/em\u003e Using the Timed Up \u0026amp; Go test in a clinical setting to predict falling in Parkinson\u0026apos;s disease. \u003cem\u003eArchives of physical medicine and rehabilitation\u003c/em\u003e \u003cstrong\u003e94\u003c/strong\u003e, 1300\u0026ndash;1305 (2013). https://doi.org/10.1016/j.apmr.2013.02.020\u003c/li\u003e\n\u003cli\u003ePearson, M. J., Lindop, F. A., Mockett, S. P. \u0026amp; Saunders, L. Validity and inter-rater reliability of the Lindop Parkinson\u0026apos;s Disease Mobility Assessment: a preliminary study. \u003cem\u003ePhysiotherapy\u003c/em\u003e \u003cstrong\u003e95\u003c/strong\u003e, 126\u0026ndash;133 (2009). https://doi.org/10.1016/j.physio.2009.02.003\u003c/li\u003e\n\u003cli\u003eJanssen, M. F.\u003cem\u003e et al.\u003c/em\u003e Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study. \u003cem\u003eQual Life Res\u003c/em\u003e \u003cstrong\u003e22\u003c/strong\u003e, 1717\u0026ndash;1727 (2013). https://doi.org/10.1007/s11136-012-0322-4\u003c/li\u003e\n\u003cli\u003eJenkinson, C., Fitzpatrick, R., Peto, V., Greenhall, R. \u0026amp; Hyman, N. The Parkinson\u0026apos;s Disease Questionnaire (PDQ-39): development and validation of a Parkinson\u0026apos;s disease summary index score. \u003cem\u003eAge Ageing\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 353\u0026ndash;357 (1997). https://doi.org/10.1093/ageing/26.5.353\u003c/li\u003e\n\u003cli\u003eKazis, L. E., Anderson, J. J. \u0026amp; Meenan, R. F. Effect sizes for interpreting changes in health status. \u003cem\u003eMed.Care\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, S178\u0026ndash;S189 (1989). \u003c/li\u003e\n\u003cli\u003eCohen, J. A power primer. \u003cem\u003ePsychological Bulletin\u003c/em\u003e \u003cstrong\u003e112\u003c/strong\u003e, 155\u0026ndash;159 (1992). \u003c/li\u003e\n\u003cli\u003eRadder, D. L. M.\u003cem\u003e et al.\u003c/em\u003e Physiotherapy in Parkinson\u0026apos;s Disease: A Meta-Analysis of Present Treatment Modalities. \u003cem\u003eNeurorehabilitation and neural repair\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e, 871\u0026ndash;880 (2020). https://doi.org/10.1177/1545968320952799\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Box","content":"\u003cp\u003eBox is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"41e785d6-e9ef-43b3-88fd-27d8701a1f2e","identifier":"10.13039/501100000266","name":"Engineering and Physical Sciences Research Council","awardNumber":"EP/S019219/1","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Leeds","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rehabilitation, Parkinson’s disease, Augmented Reality","lastPublishedDoi":"10.21203/rs.3.rs-9117546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9117546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParkinson\u0026rsquo;s is a neurodegenerative condition causing movement impairments and increasing peoples\u0026rsquo; risk of falls. People with Parkinson\u0026rsquo;s (PwP) are advised to exercise regularly to maintain their mobility and balance, specifically using sensory cueing, which is beneficial for freezing of gait, one of the most difficult apsects of living with Parkinson\u0026rsquo;s. Maintaining an exercise programme to achieve the effective dose of rehabilitation can be challenging and becomes more difficult over time, leading to reduced function and deteriorating quality of life.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the use of Strolll, a novel cueing-based rehabilitation programme for PwP, delivered through augmented reality headsets at home.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThirty PwP were recruited. Each participant had baseline and follow-up assessments in clinic. Individual game-based rehabilitation was prescribed for home use for 6 weeks with remote monitoring and weekly telephone appointments. The primary outcome measure was the Timed-Up-and-Go (TUG). Secondary outcome measures included the Lindop Parkinson\u0026rsquo;s Assessment Scale (LPAS). Statistical analysis comprised parametric and non-parametric methods appropriate to the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-eight participants completed 6 weeks\u0026rsquo; rehabilitation; two participants withdrew. Mean TUG improved from 13.2s to10.3s (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LPAS improved from 27 to 29 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). No falls, near falls or other adverse events were reported.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNovel game-based exercises through augmented reality were successfully used to deliver rehabilitation for PwP in their homes with participants\u0026rsquo; mobility improved and no adverse effects reported. A multi-site randomised controlled trial (NIHR206530) based on the results of this feasibility trial has started, which will investigate the clinical- and cost-effectiveness of this technology.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov No.: NCT05794542 Registered 29-10-2023\u003c/p\u003e","manuscriptTitle":"Augmented reality rehabilitation at home for adults with Parkinson's disease: a feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-17 16:07:12","doi":"10.21203/rs.3.rs-9117546/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4f6410f7-a659-478a-a0ef-ad1a493026a3","owner":[],"postedDate":"March 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64480708,"name":"Physical Medicine \u0026 Rehab"}],"tags":[],"updatedAt":"2026-04-03T11:54:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-17 16:07:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9117546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9117546","identity":"rs-9117546","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}