Self-Efficacy Ingredients for Success: A Mixed-Methods Study Addressing Nonmotor Symptoms and Quality of Life in Parkinson’s Disease

Self-Efficacy Ingredients for Success: A Mixed-Methods Study Addressing Nonmotor Symptoms and Quality of Life in Parkinson’s Disease | 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 Article Self-Efficacy Ingredients for Success: A Mixed-Methods Study Addressing Nonmotor Symptoms and Quality of Life in Parkinson’s Disease Jordana Lockwich, Patrick Kitzman, Camille Peplaski, Richard Andreatta, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8175308/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Parkinson’s Disease (PD) exerts both motor and nonmotor symptoms that collectively reduce quality of life. While motor impairments are often the focus of clinical management, nonmotor symptoms such as depression, anxiety, cognitive decline, and low self-efficacy significantly contribute to decreased motivation, sedentary behavior, and diminished well-being. Addressing these multifactorial symptoms is essential to improving meaningful health outcomes and overall life satisfaction for individuals with Parkinson’s Disease. Purpose: This single subject design withdrawal design mixed-methods study aims to examine how a supportive walking intervention can enhance confidence, promote engagement in physical activity, and improve overall functional mobility for individuals with Parkinson’s Disease. Methods: Five participants with PD participated in an intensity-based walking intervention program provided in an environment with opportunities to improve self-efficacy and quality of life. PDQ-39 and Activities of balance confidence scores were obtained pre and post intervention study to assess both quality of life and mobility confidence. In addition, phenomenology qualitative semi structured interviews were completed and thematic analysis was conducted to understand the impact of the intervention on nonmotor symptoms to PD after participating in the intervention program. Results: All 5 participants demonstrated improved scores on both the PDQ and ABC, with at least 3 out of 5 participants reaching published and established minimal detectable changes within this population. Thematic analysis revealed four emerging themes common across the 5 participants which included overcoming fear, accountability, improvement, and confidence. Conclusion: Our findings support the use of interventions in a structured environment that provides opportunities to improve quality of life, confidence and self-efficacy. Choosing an environment that enhancing self-efficacy may represent a critical strategy for improving both motor and nonmotor outcomes in PD. These findings may also help inform future rehabilitation approaches aimed at promoting independence and improving overall quality of life in this population Health sciences/Diseases Health sciences/Health care Health sciences/Neurology Biological sciences/Neuroscience Biological sciences/Psychology Social science/Psychology Introduction Parkinson’s Disease (PD) exerts a multifaceted impact on individuals’ overall quality of life, encompassing both motor and nonmotor dimensions. Beyond the well-recognized motor impairments, people living with PD frequently experience a range of nonmotor symptoms—including depression, anxiety, changes in taste perception, cognitive difficulties, loss of interest, hallucinations, and disrupted sleep. 1 These nonmotor symptoms collectively contribute to diminished daily functioning and well-being. Understanding and addressing these multifactorial symptoms are essential to improving life satisfaction, emotional health, and overall quality of life in this population. Specially, nonmotor symptoms of depression and anxiety correlate with classical motor symptoms that impact daily life, with one study reporting up to 56% of their surveyed PD population living with depression and 54% also demonstrating anxiety 2 . These nonmotor symptoms can worsen disability and self-perceived health status 2-4 . This couple effect of motor and nonmotor symptoms can limit motivation to participate in activities that could provide opportunities to improve motor and nonmotor symptoms which results in overall sedentary behavior 5-7 . Walking difficulty unfortunately worsens with disease progression and is a major burden that directly impacts independence and quality of life 8 . Due to various components of this disease, it can be difficult to choose which interventions would be most beneficial for individuals with PD that are presenting with multifactorial problems. Though PD is most recognized by its motor features, nonmotor features also contribute to the decline in functional mobility over time 1 . Both nonmotor symptoms of depression and anxiety have been reported to reduce endurance capacity more than the classic motor features that typically define this diagnosis 9 . Nonmotor symptoms are highly correlated with low self-efficacy when it comes to disease management 9 . Self-efficacy, or confidence that one has in the ability to control his or her life, is reduced for individuals with PD when compared to their healthy peers 10 . Mastery of experience and verbal persuasion have been identified as sources to improve one’s self-efficacy. To motivate individuals with PD to participate in exercise opportunities that are intended to improve functional mobility, utilizing these sources to combat the nonmotor symptoms may also need to be addressed in selected interventions that also emphasis improving one’s self-efficacy to manage life with PD. Even though exercise provides a way to manage life with PD, the multifactorial impact of symptoms can impact both engagement and confidence in these recommended opportunities that could warrant positive results. Identified barriers to confidence in chronic disease management such as lack of knowledge, overwhelming new situations and limited time with healthcare practitioners can negatively impact ones belief that they can take action and reach meaningful goals 11 . If individuals do not have the confidence, or the innate belief, to control their own lives, then this can lead to diminished life satisfaction, self-esteem, physical health, functional status, and quality of life 12 . Confidence with participating in daily mobility tasks is poor for individuals with PD and associated with worsening of motors symptoms which can lead to an increase in fall risk and poor quality of life 13 . This research aims to identify a walking intervention provided in a supportive environment that enhance self-efficacy, promote engagement in exercise, and ultimately improve overall quality of life for people with PD. The primary goal of this study is to addresses the nonmotor symptoms of PD to improve clinical meaningful outcomes. Methods Study Design: A single subject design was chosen for this study, which included a baseline condition (A1), intervention condition (B2), withdrawal condition (A2) and a second intervention condition (B2) 14 . Baseline conditions (A1) consisted of outcome data collection only. Interventions phases (B1 & B2) included an intensity driven treadmill walking program delivered by a PT one-on-one and outcome collection. The withdrawal phase (A1) included a removal of the treadmill walking program and only outcome data collection. To address the nonmotor components of PD, all conditions of this study were delivered in an environment that provided opportunities to develop participant self-efficacy. Both sources were utilized during this study to achieve optimal outcomes. All study protocols were reviewed and approved by both the University of Kentucky and the University of Evansville Institutional Review Boards and research procedures were performed in accordance with relevant institutional guidelines and regulations. Subjects Five individuals were recruited for this study from a convenience sample of individuals that were diagnosed with PD living in the Evansville, Indiana region. Included in this study were individuals with mild to severe PD (Hoehn and Yahr scale stages 1-4) that were ambulatory, were not participating in intensity-based exercise routines and where not currently receiving any physical therapy. Excluded in this study were individuals with severe PD (H&Y scale stage 5) and those individuals that had recent cardiac and/or orthopedic problems that limited mobility. Individuals with severe PD were excluded because the outcomes chosen for this study were validated only in the mild to moderate diseases severity range. All interested participants were presented with a detailed explanation of the study procedures, associated risks, and potential benefits during an initial informational session. Individuals were given the opportunity to ask questions and review the consent materials, after which written informed consent was obtained prior to enrollment in the study. Physician’s clearance was required prior to start of program. Participants were then introduced to the equipment and the lab space that would be utilized for the study. Table 1 provides demographics information for all individuals that participated in the study. Table 1 Demographics Participant 1 2 3 4 5 Age 71 49 76 68 65 Sex Female Female Male Male Male # Years with PD 9 14 2 9 11 PD Severity (H&Y Stage) Mild (2) Moderate (4) Mild (1) Moderate (3) Moderate (4) Procedures To control for procedural infidelity, adherence to implementation measures were maintained throughout study 14 . A predetermined criteria checklist of all procedures was placed in the file of each participant, which contained both a list of setup procedures and explicit outcome of interest. Checklists were reviewed prior to each session to maintain integrity of data collection To avoid threats to internal validity, each phase was continued until stability was reached to avoid learning effects 14 . A novel treadmill platform was only used during condition B1 and B2 intervention phases to reduce carryover effects. Baseline and Withdrawal Phases (A1, A2): During baseline and withdrawal phases only outcomes were collected and these sessions were shorter (around 20 minutes). The next phases were initiated after predictable and stable data was present during conditions. Withdrawal periods included immediate removal of the walking intervention. Individuals were instructed to continue to participate in normal activities for daily living during these periods. Intervention Phase (B1, B2): Intervention phases included a 30-minute individualized moderate intensity driven treadmill walking program. Initial treadmill speeds were set at predetermined individualized gait speed levels obtained from baseline 10-meter walk test results.Heart rate maximum was calculated (HrMax= 208 – (.7 x age) and used to set a target moderate intensity heart rate goal at 65% of an individual’s HrMax 15 . Heart rate was monitored closely by Polar H10 Heart Rate Sensors (Polar) throughout intervention phases. No participants were currently taking beta blockers that would blunt cardiovascular response. Rate of Perceived Exertion (RPE) was also used to assess perceived intensity levels and were targeted at 14-17 (hard to very hard). Exercise was discontinued if vital signs fell outside the recommended cardiovascular guidelines 16 or if RPE scores were higher than 17. Environment to boost self-efficacy All sessions were conducted one-on-one with a physical therapist. A body weight support system was utilized during all treadmill sessions to only provide support with no de-weighting applied to the individual. The BWS harness helped to reduce fear of falling during intervention trials, improve confidence in exercise, and provide an overall safe environment to exercise. Sessions included verbal guidance throughout conditions on outcome performance and progress made during sessions. One-on-one verbal motivation was delivered throughout as well to promote encouragement, point out accomplishments, and discuss overall progress in achievable goals. Reaching the target heart rate zones was encouraged during the intervention periods and participant goals were set during sessions to increase duration in the cardiovascular zones. Each participant was made aware of the target heart rate goal for the desired moderate intensity level for each session. Throughout the session, the participant had both a visual reminder of what their current heart rate was as well as verbal reminders from the PT. Encouragement was given once individuals reached their target heart rate zone to continue to work at that level to induce a positive cardiovascular response. The study design allowed for individuals to experience changes in endurance that were presented to them in session updates at the beginning and end of sessions. Each participant was made aware of the progress on desired outcomes to fuel motivation in achieving improved endurance throughout the study. Table 2 summarizes the environmental strategies that were utilized in the intervention to address in this study to address sources to improve self-efficacy 17,18 . Table 2: Environmental strategies to boost self-efficacy Outcomes The Activities Of Balance Confidence (ABC) was selected from the neurological core set of clinical measures 27 to measure confidence and the PDQ-39 19 mobility scale was also selected to assess overall quality of life. A descriptive qualitative study was also completed to understand the experience of participating in the selected intervention from the perspective of the participant. Data Analysis ABC and PDQ-3 mobility scores produced were compared to MDCs (standard measures of error, SEM, were also used if an MDC wasn’t available) and significance was determined if minimal scores were reached or above the threshold for error. Thematic analysis was completed following individual interviews to determine common threads within the conversations. Results Table 3 presents data for all outcome measures including minimal and maximal performances, pre and post intervention differences as well as compared results to published MDCs within the PD population. The datasets used and analyzed during this current study are available from the corresponding author on a reasonable request. Table 3 Pre and Post Intervention Results for PDQ39 mobility and ABC Across Participants Participant 1 2 3 4 5 PDQ39(mobility) Pre-Intervention 22.5 47.5 2.50 32.5 52.21 Post Intervention 14.5 22.5 0 17.5 33.21 Change 8 25 2.50 15 19 MDC yes yes no yes yes ABC (%) Pre-Intervention 62.25 66.25 98.75 62.8 83.75 Post Intervention 76.19 71.6 99.39 83.75 64.38 Change (+)13.94 (+)5.35 (+)0.61 (+)20.95 (+)18 MDC yes no no yes yes QOL: The PDQ-39 was administered to assess quality of life after participation in an moderate intensity driven walking program. This study chose to only focus on the mobility subscale secondary to selected outcomes of interest looking at functional mobility as the primary goal. Analysis of the PDQ-39 mobility subscale, a scale that assesses percentage of perceived disability from 0% (no impairments) to 100% full impairment, revealed that 4 participants that had detected mobility QOL impairments at baseline (range 22.5% - 55.21%) reached minimal detectable thresholds after participation in an moderate intensity driven intervention program. An average improvement of 16.75% was noted for participants 1,2,4 and 5 on mobility subscale questions. Qualitative Interviews: A descriptive qualitative study, in addition to the PDQ-39 mobility assessment was completed, to further investigate the nonmotor impacts of PD. The interviews aimed to understand the experience of participating in an intensity-based exercise program from the perspective of the individual. Open ended interview questions were asked in the research laboratory where the study took place and remarks were transcribed verbatim by the primary investigator. Specific questions focused on how individuals felt after participating in an intensity-based intervention and if they perceived any notable changes during their daily routines. Thematic analysis was conducted following the interviews to search and identify common threads that were used to describe the overall experience of participating in a moderate intensity walking program across all 5 participants 20 . Analysis revealed four emerging themes common across the 5 participants which included overcoming fear, accountability, improvement, and confidence. Theme 1 - Overcoming fear : Our participants were generally at first hesitant about trying a new, unfamiliar exercise intervention. Feelings of fear and uncertainty were expressed with trying something that was not a part of their daily routines which made them also feel nervous at the start of the study. Doubt of individual abilities was also a common occurrence when asked about the experience of participating in a walking program that was going to be delivered on a treadmill. None of the 5 participants had previously used a treadmill for exercise. The fear of not knowing what to expect and of the possibility of failure was a common theme throughout the interviews. However, the sense of accomplishment after completing the intervention was reflected in the strength and surprise of being able to achieve exercise levels that were at first thought to be impossible. The participants expressed: “Scared that it was going to be challenging but it wasn’t too bad” “It was hard at first then got easier” “I wasn’t able to walk as far from the start but then I surprised myself” “I didn’t think I could but then I was able to finish” Theme 2 – Accountability: Motivation to participate in our selected intervention came from not only wanting to improve their walking but also was fueled by adhering to a responsibility to themselves, the primary investigator, other individuals with PD and their families. The ability to be a part of a research project gave a purpose to the participants and held them responsible to fulfilling an obligation. Participant 3 felt that it was his duty to participate in research opportunities so that other individuals with PD could benefit in the future. Participant 2 said that her husband has been pushing her to exercise more and used this as motivation to seek out opportunities that were available in the community. Overall, the individuals shared: “I didn’t want to let you down” “I want to keep it up, it has been good for me” “If I can help someone else with PD then it was worth it” “I want to work out because I have somewhere to go” “My husband has really been on my case about exercising more” “ PD shut my world down. This gave me a purpose” Theme 3 – Improvement: Overall, the experience of this intervention was well received which was made apparent in the activities that were now possible or easier since starting the intervention. Functional mobility gains were noted in routine activities that were meaningful to the participants. When asked about changes and activities they could now do the participants stated: “I am able to walk my dog more” “I can get around the block faster than I did” “My balance feels better” “Getting up from a chair is easier” “I lost weight” “I can walk across a street faster in a big city” Theme 4 – Confidence: Finally, there was a notable increase in daily life confidence that was not only reflected in personal experiences but from the perspective of surrounding family members as well. When asked what was different now in their daily lives after participating in this study, the participated noted: “I can walk to the parking lot without getting out of breath” “My family noticed I wasn’t so tired” “I can now cross the street faster with my son” “My husband was surprised that I mowed the lawn for the first time in 4 years” “I can get the mail without getting tired and help around the house” Discussion A comprehensive understanding of personal benefits that were achieved at the end of our study was reflected not only in the qualitative remarks but in the quantitative improvements on both PDQ-39 and ABC scores. All 5 participants demonstrated improved scores on both the PDQ and ABC, with at least 3 out of 5 participants reaching established MDC. Overall, participants in this study overcame fear and doubt about participating in a new intensity driven exercise program by utilizing motivation found within themselves and others around them to achieve salient improvements in their daily lives. Addressing the nonmotor symptoms of PD is needed by targeting known barriers to exercise that currently exist. Known barriers to exercise such as low outcome expectation and poor motivation have been found to limit participation in exercise 21 . Low outcome expectations and poor motivation are commonly expressed secondary to the progressive nature of PD when individuals are not expecting to see benefits 22 . Fear of falling, another common reported barrier, has been associated with restricted activity levels 23-25 .Regardless of the known benefits to exercise, if barriers are not addressed, then individuals will not seek out opportunities to manage life with PD. Persistence to overcome common barriers of exercise are also influenced by ones self-efficacy 26 . Self-efficacy, rather than disability, appear to be strongly associated with whether ambulatory individuals with PD exercise regularly 27 . Our study focused on providing an environment that would address the sources of self-efficacy. Individuals were given an opportunity to work one-on-one with a PT that had experience in working with individuals with neurological disorders. The American Academy of Neurology advocates not only for individuals with PD to participate in exercise to manage symptoms of PD, but also recommended regular physical therapist assessments to be completed at least twice a year 28 . Our study provided an opportunity for individualized sessions from a neurological specialist PT that had knowledge in gait, mobility, and PD specific interventions. Utilizing an intervention that addressed not only the motor symptoms, but the multifactorial components of PD as well, provided the optimal solution to addressing this variable disorder. By addressing individual self-efficacy through safety mechanisms, mastery of experiences and positive verbal persuasion, we were able to motivate exercise participation. Providing an environment that was safe was implemented to attempt to reduce exercise induced anxiety. Utilizing a body weight support (BWS) harness provided a mechanism in which individuals with PD could exercise without the fear of falling or losing their balance, both common subsequent complications of this disorder 29 . BWS has been shown to reduce dropout rates, improve mobility and decrease overall anxiety with exercise practice in other neurologic populations 30 . In addition to providing a safe environment, opportunities to improve both confidence and motivation were included that were delivered by the PT to boost participant self-efficacy. Self-efficacy, rather than disability, appear to be strongly associated with whether ambulatory individuals with PD exercise regularly and those that demonstrate poor motivation tend to exercise less 27 . The selection of a single subject design boosted motivation for individuals in which they were to complete against themselves. Session updates throughout the study provided individuals with up-to-date progress on outcome measures that they could see being graphed. Verbal motivation provided by the PT during sessions gave structured goals that were obtainable, and reminders of how hard individuals were working. This attention provided to improve participant self-efficacy drove motivation to continue with the exercise program which was evident in the zero attrition rates of this study. Both motor and nonmotor factors needs to be addressed to see substantial improvements in functional mobility for individuals with PD. Finally, the impact of addressing this multifactorial disorder was reflected in the gains noted in quality of life. This was another focus of our study because QOL has been reported to be highly correlated with motor impairments involving difficultly with walking, speaking, and maintaining balance 31 . In addition, nonmotor symptoms of cognition, stigma, body discomfort and emotional well-being have also been identified as key contributors to QOL 31 . This again reinforces the importance of recognizing both the motor and nonmotor symptoms of PD and providing options to target all aspects of this progressive, neurodegenerative disorder that currently has no cure. After participation in a intensity driven exercise intervention our study found that 4 out of the 5 of the participants reported substantial changes in their functional mobility QOL Improvements across all 5 participants were noted on item number 4, “Have you had problems walking a mile” and item number 7 “Have you had difficulty getting around in public”. Both questions identify the importance of endurance to participate in activities outside the home. It seems to be that the gains made after participating in the study not only improved confidence in distance but were also able to be generalized to daily functional mobility activities that are required to be independent in the community. The increased confidence in functional mobility was reflected in significant gains made on the PDQ-39 and provides an understanding of the impact of this program on overall perceived quality of life. Qualitive reflections provided by our participants strengthened our confidence that our intervention had a meaningful impact on daily lives. Addressing self-efficacy throughout our intervention allowed individuals to overcome fears about trying new evidence-based exercise interventions to combat this multifactorial disability. Addressing possible sources for anxiety by providing a supportive environment that included individualized assistance and a body weight support to reduce the fear of falling allowed participants to focus on improving motor impairments. Motivation to improve was provided not only from the primary investigator but surrounding support systems that were already in place for the participants. Neurological disorders, especially PD being progressive, not only impacts the individual but the surrounding family as well. Even though there were significant changes noted on the PDQ-39 mobility scale scores to draw attention to improved quality of life, the biggest gains were heard in the verbal improvements in daily activities that included family involvement. Though participants all mentioned positive changes in their day, participant 2 demonstrated one of the most substantial differences that was reflected from a family members perspective. Participant 2 mentioned: “I can’t believe it. I was able to keep up with my son for the first time while crossing the street to his soccer game and walking across the field to where he needed to meet his team. For the first time, in a long time, I don’t think he was embarrassed to be seen with me. I just felt normal”. Qualitative remarks from participant 2 remind us of the daily struggles that individuals with PD face. Living with PD is a life altering disorder that can result in social embarrassment that may be from motor symptoms, non-motor symptoms, loss of autonomy, or from the need for help 32 . Regardless of the source, all these factors impact not only QOL but activities that were once able to be completed without any struggle that allowed for family. To fully address the multifactorial impact of PD, interventions need to target all aspects of this disorder to see optimal results and return some control back into lives that have been turned upside down from this progressive neurological disorder. Study Limitations When interpreting the results of this study external validity is limited due to the small sample size. Direct intra-participant replication was achieved which will allow for future larger studies to replicate the results. Inter-observer agreement and procedural reliability was not collected concurrently throughout conditions which could have strengthened the validity of study finds. Conclusions Providing the most beneficial interventions for individuals with PD is challenging due to the variety of symptoms that encompass this disorder. Both motor and nonmotor impairments associated with PD directly impacts one’s functional mobility potential. Despite the progressive nature of PD, this relationship between personal factors and exercise offers optimism for individuals with PD and clinicians treating this disorder. This relationship suggests that improvements are potentially modifiable. If we can exhibit control over one’s exercise behavior then we can improve symptoms, regardless of the defined disability. When designing intervention programs for individuals with PD, one should include strategies to increase one’s exercise self-efficacy as well as functional mobility for optimal achievable outcomes. These findings support the use of interventions in a structured environment that provides opportunities to improve self-efficacy. 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Journal of rehabilitation and assistive technologies engineering . 2016;3:2055668316676047-2055668316676047. doi:10.1177/2055668316676047 Tu X-J, Hwang W-J, Ma H-I, Chang L-H, Hsu S-P. Determinants of generic and specific health-related quality of life in patients with Parkinson's disease. PloS one . 2017;12(6):e0178896-e0178896. doi:10.1371/journal.pone.0178896 Angulo J, Fleury V, Péron JA, Penzenstadler L, Zullino D, Krack P. Shame in Parkinson'S Disease: A Review. Journal of Parkinson's disease . 2019;9(3):489-499. doi:10.3233/JPD-181462 Additional Declarations No competing interests reported. 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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-8175308","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":618378110,"identity":"f8cdada2-6622-4a6a-b333-b2dec5062882","order_by":0,"name":"Jordana Lockwich","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACPgYGZgYGA4YExvYGA5AAYwMhLWxwLT0HSNLCwJDAIJFArBb25sfGPAV2ecwzH2+TeMNgI7vhACEtPMeMk3kMkosZZ6eVSc5hSDMmrEUih/lwjsGBxMbZOWbSPAyHE0nQMvMMSMt/4rQkg7XM4AFpOUCEFqBfjP8YJCc29qQVW84xSDaeSUgLPzDEJGf8sUvc2H544403FXayfYS0wIFhA5DgMSBWOQjIgwgeUnSMglEwCkbBiAEAVbg+6URM6JQAAAAASUVORK5CYII=","orcid":"","institution":"Duquesne University","correspondingAuthor":true,"prefix":"","firstName":"Jordana","middleName":"","lastName":"Lockwich","suffix":""},{"id":618378111,"identity":"c4529002-9f8a-4f9d-900b-047f174cb1db","order_by":1,"name":"Patrick Kitzman","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Kitzman","suffix":""},{"id":618378112,"identity":"91c08af4-a49b-446a-84d8-4cb247b8e544","order_by":2,"name":"Camille Peplaski","email":"","orcid":"","institution":"Eastern Kentucky University","correspondingAuthor":false,"prefix":"","firstName":"Camille","middleName":"","lastName":"Peplaski","suffix":""},{"id":618378113,"identity":"9c32d520-7c0e-4b28-a948-a8a16ccd2b0e","order_by":3,"name":"Richard Andreatta","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Andreatta","suffix":""},{"id":618378114,"identity":"6b69e3c1-e41c-4796-a4b7-cbfd120ab702","order_by":4,"name":"Kate Phifer","email":"","orcid":"","institution":"University of Evansville","correspondingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Phifer","suffix":""}],"badges":[],"createdAt":"2025-11-21 16:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8175308/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8175308/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106960168,"identity":"3dd8e5ba-4c83-4ba8-8dc4-6b9fa66701ca","added_by":"auto","created_at":"2026-04-15 09:19:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":471802,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8175308/v1/d45ca50c-cadd-4c3a-a2e9-ece64dc90410.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Self-Efficacy Ingredients for Success: A Mixed-Methods Study Addressing Nonmotor Symptoms and Quality of Life in Parkinson’s Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eParkinson’s Disease (PD) exerts a multifaceted impact on individuals’ overall quality of life, encompassing both motor and nonmotor dimensions. Beyond the well-recognized motor impairments, people living with PD frequently experience a range of nonmotor symptoms—including depression, anxiety, changes in taste perception, cognitive difficulties, loss of interest, hallucinations, and disrupted sleep. \u003csup\u003e1\u003c/sup\u003e These nonmotor symptoms collectively contribute to diminished daily functioning and well-being. Understanding and addressing these multifactorial symptoms are essential to improving life satisfaction, emotional health, and overall quality of life in this population.\u003c/p\u003e\n\u003cp\u003eSpecially, nonmotor symptoms of depression and anxiety correlate with classical motor symptoms that impact daily life, with one study reporting up to 56% of their surveyed PD population living with depression and 54% also demonstrating anxiety \u003csup\u003e2\u003c/sup\u003e. These nonmotor symptoms can worsen disability and self-perceived health status\u003csup\u003e2-4\u003c/sup\u003e. This couple effect of motor and nonmotor symptoms can limit motivation to participate in activities that could provide opportunities to improve motor and nonmotor symptoms which results in overall sedentary behavior \u003csup\u003e5-7\u003c/sup\u003e. Walking difficulty unfortunately worsens with disease progression and\u0026nbsp;is a major burden that directly impacts independence and quality of life\u0026nbsp;\u003csup\u003e8\u003c/sup\u003e. Due to various components of this disease, it can be difficult to choose which interventions would be most beneficial for individuals with PD that are presenting with multifactorial problems.\u003c/p\u003e\n\u003cp\u003eThough PD is most recognized by its motor features, nonmotor features also contribute to the decline in functional mobility over time\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e.\u0026nbsp;Both nonmotor symptoms of depression and anxiety have been reported to reduce endurance capacity more than the classic motor features that typically define this diagnosis\u003csup\u003e9\u003c/sup\u003e. Nonmotor symptoms are highly correlated with low self-efficacy when it comes to disease management\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSelf-efficacy, or confidence that one has in the ability to control his or her life, is reduced for individuals with PD when compared to their healthy peers \u003csup\u003e10\u003c/sup\u003e. Mastery of experience and verbal persuasion have been identified as sources to improve one’s self-efficacy. To motivate individuals with PD to participate in exercise opportunities that are intended to improve functional mobility, utilizing these sources to combat the nonmotor symptoms may also need to be addressed in selected interventions that also emphasis improving one’s self-efficacy to manage life with PD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEven though exercise provides a way to manage life with PD, the multifactorial impact of symptoms can impact both engagement and confidence in these recommended opportunities that could warrant positive results. Identified barriers to confidence in chronic disease management such as lack of knowledge, overwhelming new situations and limited time with healthcare practitioners can negatively impact ones belief that they can take action and reach meaningful goals \u003csup\u003e11\u003c/sup\u003e. If individuals do not have the confidence, or the innate belief, to control their own lives, then this can lead to diminished life satisfaction, self-esteem, physical health, functional status, and quality of life \u003csup\u003e12\u003c/sup\u003e. Confidence with participating in daily mobility tasks is poor for individuals with PD and associated with worsening of motors symptoms which can lead to an increase in fall risk and poor quality of life \u003csup\u003e13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research\u0026nbsp;aims to identify a walking intervention provided in a supportive environment that enhance self-efficacy, promote engagement in exercise, and ultimately improve overall quality of life for people with PD.\u0026nbsp;The primary goal of this study is to addresses the nonmotor symptoms of PD to improve clinical meaningful outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003eStudy Design: A single subject design was chosen for this study, which included a baseline condition (A1), intervention condition (B2), withdrawal condition (A2) and a second intervention condition (B2) \u003csup\u003e14\u003c/sup\u003e. Baseline conditions (A1) consisted of outcome data collection only. Interventions phases (B1 \u0026amp; B2) included an intensity driven treadmill walking program delivered by a PT one-on-one and outcome collection. The withdrawal phase (A1) included a removal of the treadmill walking program and only outcome data collection. To address the nonmotor components of PD, all conditions of this study were delivered in an environment that provided opportunities to develop participant self-efficacy. Both sources were utilized during this study to achieve optimal outcomes. All study protocols were reviewed and approved by both the University of Kentucky and the University of Evansville Institutional Review Boards and research procedures were performed in accordance with relevant institutional guidelines and regulations.\u003c/p\u003e\n\u003cp id=\"_Toc89368155\"\u003eSubjects\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFive individuals were recruited for this study from a convenience sample of individuals that were diagnosed with PD living in the Evansville, Indiana region. Included in this study were individuals with mild to severe PD (Hoehn and Yahr scale stages 1-4) that were ambulatory, were not participating in intensity-based exercise routines and where not currently receiving any physical therapy. Excluded in this study were individuals with severe PD (H\u0026amp;Y scale stage 5) and those individuals that had recent cardiac and/or orthopedic problems that limited mobility. Individuals with severe PD were excluded because the outcomes chosen for this study were validated only in the mild to moderate diseases severity range.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll interested participants were presented with a detailed explanation of the study procedures, associated risks, and potential benefits during an initial informational session. Individuals were given the opportunity to ask questions and review the consent materials, after which written informed consent was obtained prior to enrollment in the study.\u0026nbsp;Physician\u0026rsquo;s clearance was required prior to start of program. Participants were then introduced to the equipment and the lab space that would be utilized for the study. Table 1 provides demographics information for all individuals that participated in the study.\u003c/p\u003e\n\u003cp id=\"_Toc89372480\"\u003eTable 1 Demographics\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"537\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eParticipant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eSex \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e# Years with PD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003ePD Severity\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(H\u0026amp;Y Stage)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003eMild (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModerate (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eModerate (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eModerate (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp id=\"_Toc89368157\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProcedures\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo control for procedural infidelity, adherence to implementation measures were maintained throughout study \u003csup\u003e14\u003c/sup\u003e. A predetermined criteria checklist of all procedures was placed in the file of each participant, which contained both a list of setup procedures and explicit outcome of interest. Checklists were reviewed prior to each session to maintain integrity of data collection To avoid threats to internal validity, each phase was continued until stability was reached to avoid learning effects \u003csup\u003e14\u003c/sup\u003e. A novel treadmill platform was only used during condition B1 and B2 intervention phases to reduce carryover effects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBaseline and Withdrawal Phases (A1, A2): During baseline and withdrawal phases only outcomes were collected \u0026nbsp;and these sessions were shorter (around 20 minutes). The next phases were initiated after predictable and stable data was present during conditions. Withdrawal periods included immediate removal of the walking intervention. Individuals were instructed to continue to participate in normal activities for daily living during these periods.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntervention Phase (B1, B2): Intervention phases included a 30-minute individualized moderate intensity driven treadmill walking program. Initial treadmill speeds were set at predetermined individualized gait speed levels obtained from baseline 10-meter walk test results.Heart rate maximum was calculated (HrMax= 208 \u0026ndash; (.7 x age) and used to set a target moderate intensity heart rate goal at 65% of an individual\u0026rsquo;s HrMax \u003csup\u003e15\u003c/sup\u003e. Heart rate was monitored closely by Polar H10 Heart Rate Sensors (Polar) throughout intervention phases. No participants were currently taking beta blockers that would blunt cardiovascular response. Rate of Perceived Exertion (RPE) was also used to assess perceived intensity levels and were targeted at 14-17 (hard to very hard). Exercise was discontinued if vital signs fell outside the recommended cardiovascular guidelines \u003csup\u003e16\u003c/sup\u003e or if RPE scores were higher than 17.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEnvironment to boost self-efficacy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll sessions were conducted one-on-one with a physical therapist. A body weight support system was utilized during all treadmill sessions to only provide support with no de-weighting applied to the individual. The BWS harness helped to reduce fear of falling during intervention trials, improve confidence in exercise, and provide an overall safe environment to exercise. Sessions included verbal guidance throughout conditions on outcome performance and progress made during sessions. One-on-one verbal motivation was delivered throughout as well to promote encouragement, point out accomplishments, and discuss overall progress in achievable goals. Reaching the target heart rate zones was encouraged during the intervention periods and participant goals were set during sessions to increase duration in the cardiovascular zones. Each participant was made aware of the target heart rate goal for the desired moderate intensity level for each session. Throughout the session, the participant had both a visual reminder of what their current heart rate was as well as verbal reminders from the PT. Encouragement was given once individuals reached their target heart rate zone to continue to work at that level to induce a positive cardiovascular response. The study design allowed for individuals to experience changes in endurance that were presented to them in session updates at the beginning and end of sessions. Each participant was made aware of the progress on desired outcomes to fuel motivation in achieving improved endurance throughout the study. Table 2 summarizes the environmental strategies that were utilized in the intervention to address in this study to address sources to improve self-efficacy \u003csup\u003e17,18\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTable 2: Environmental strategies to boost self-efficacy\u003c/p\u003e\n\u003cp\u003e\u003cimg 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paUxZkafxM8B0Up6kv+PP5HUaGwxnuSIGbmZL5GbPTHP6qgzX+FwWPh8PhEIBERzc7PweDwyPZPJyHSHwyGam5st25lnZcLhsHA4HCIQCMjF4XDIssx1Mng8HjE+Pi7Gx8dnnOGZbeZLmGa/zDNRYob9Ge/nQuuqznwhNzNmbOvz+Sxlq8diLk8t2ywQCAiPx2Op12z5VzOj/3Ap3EJEC8O+Yy/OfCkzN2bmma9kMomKigrcu3dPzhjpuo7t27ejoaEBiUTCMnNUVVWF7u5ulJeXT5vh6ejowM2bN2e8AzJfnczXSn3/+9+XM21m5vrk09LSgqmpKQwODsq6Ic/+1JmvhdQ138zXzZs3887qqO2CBc58VVRUyAcGP8mM/jM+Pq4m0QK98MILwBM6FhGtpCf5//gTSY3GFuNJjpgxy2yJeeYrHo9bZsX6+vosM0AOh0OWo14P1tPTI3w+nyw3lUrJmSxzfuOasXx1SqVSwuFwWK7NUs028xWPx+U1Uua/RW5/5mur1Gu+FlJXdearublZ1NbWytft7e2yLeaa+VKv+TJf19XX12dpi/HxcQHT9WJPkie5/6w2bEuixWHfsRfvdpyn8vJy1NbWori4GE6nE19++SVKS0tl+s2bN1FfXw+/34+ysjIEg0E5Y6M+dsTtdqO1tRXV1dXQNA2bN2/G4cOHsWPHDtMerdxuNzweD/x+/6w/49DY2Agtz+981dfXo7W1FS6XC+Xl5fD5fPjwww/ldh6PB2VlZdByd1Z+8sknQG6/C62rmfEYE6MuV65cQVdXl5otr5///OdwOp0oLi6W24bDYQDgY0iIiOiJte5POz4pstksysrKcPny5byn8JbCfKqP7Mf+UzhsS6LFYd+xF2e+ngCRSATFxcUIBoMFD7yIyD7q7+AthLqt8Tt5RPTkYfD1BGhoaIAQAr/4xS/UpIIQQnDWi4ik/v5+y00+RFRYDL6IaE0znqIQCoWgaRqcTqd8ugNyvw1mPBfV6XTKO3uNJzuY82maZrnzV9f1aXcCz/VkBuR+c8/8RAkz44kPXq8Xfr9/2rYzUfe7kKdJGE/N0HUdXq8Xra2t2Lt3r0zL1z7I7dOcxoCNaH4YfBHRmnfmzBkcOXIEQgg0NTXhvffek2nV1dXYvXs3hBC4d+8e3n33XSQSCezYsQOTk5My+BkYGIDH48Hnn38O5AKPgYEBVFZWyrIA4Kc//SkmJyeRyWQghMBLL72EkydPWvJ8/vnnuHXrFjKZDCYmJmQwGI1G0dvbi3v37mFiYgKHDh1CY2OjZduZGPsVuWe6plIpS4A1MDCAZ599FpOTk4jH42hsbJSP5KqurkZ3dzdisRhu3bqFgYEBbNiwQablax8AOHv2LF566SWZNjg4OC0YJaLpGHwR0ZrX1NQkT62//PLLGB0dBXKzOqlUSv5enMvlQjAYxPDwMACgqqoK/+f//B8AwI0bN9Da2iqDi1u3biEQCEy7wzYajeLIkSNy/S9+8YtpAUlbWxtcLhdcLhe8Xi++/PJLAEBpaSkuX74sty0qKpr21IqZGPs1HDx4EDdu3JCvA4GAPE6jLb766iuZns9c7VNUVITBwUEZPHZ1dVnuAiei/Bh8EdG69ejRIyB3+tBYent7ZdDy+uuv48qVK8hmsxgZGcGOHTvg8XiQTCbx+9//Hrt371ZKBKamptRV8/bo0SOcPHkSfr8foVBIzrLNx9TUFOrr6+VxvPfee/MO3I4fP46tW7dC13WUlZWhp6cHbrd7zvapqanBW2+9hdbWVhQXF+PkyZMoKipSSiciFYMvIlq3NmzYAIfDgVgsJpeJiQn51IXKykoMDAxgaGhIPlWiqqoKAwMD6O3tnXbKEQAcDoe6at5OnjyJLVu24Pbt24hGo/jBD36gZpmRw+FAV1eXPI7bt2/P+2cD3nnnHaRSKXn8xrHO1T7JZBKVlZWIxWLIZDJA7lQkEc2OwRcRrVslJSXweDyW04KhUEheOO5yuRAIBPDuu+/i7//+7wEAr7zyCjo7O+FwOKY93B657U+fPi2vp+ro6Jh2Uf1M7t+/L//OZrM4ffq0fG1cg2WUW1RUJP8GgNraWnR0dMjXHR0d8Pv98vVsmpqa4PF45MX6fr8fiURizvY5efKkDLbU069ENDMGX0S0rnV1daG7u1sGHk6nUz6ZAQB2796NVColZ7nKy8sxOTmJqqoqUyl/MduTGeYSDofR2dkJTdOwf/9+VFRUyLSSkhIEAgEUFxcjkUigsrISU1NT0HK//bXYp0mk02lcvHhR3iAghMChQ4dw4sQJYI72+eijjzA2Ngav1yvvDH3zzTct5RPRdPyFe6IVxv5TOGzLhUsmk6iursatW7fk7FVHRwdu3rw57UYBWrvYd+zF4ItohbH/FA7bcnEikQg6Ozvh9XoxMTEBn8+Hjz76iKcS1xH2HXsx+CJaYew/hcO2JFoc9h178ZovIiIiIhsx+CIiIiKyEYMvIiIiIhsx+CIiIiKyEYMvIiIiIhsx+CIiIiKyEYMvIiIiIhsx+CIiIiKyEYMvIiIiIhsx+CIiIiKyEYMvIqJZRCIRpNNpdTUR0aLx2Y5EK4z9p3CWoy01TUM8Hkd5ebmaRLRmLEffoZlx5ouI1rRsNou6ujpomgZN0xAKhZDNZmW6pmlIJBLydSQSga7rMg0Atm7dKtcZeZxOJzRNg9frRX9/v0zr7++H1+uVadFo1LKdrutoaWmBpmlwOp2IRqOWbcz7MbYx9qXruqXuRjn5jouIVi8GX0S0pn344YeYnJyEEAJCCHg8Huzfv1/NlpcxCxCPxxGLxQAA0WgUnZ2dGB0dhRACra2tOHDgAAAgnU7jwIEDuHz5MoQQGBwcRF1dnSW4GxgYwPe//30IIfDxxx+jrq4O169fx61bt5DJZDAyMiLzG/u6d+8ehBDYvXu3rHsikcDg4KA8LqfTiZ/+9KdyP0S0ejH4IqI17cyZMzhy5Ih8fezYMQwMDCCZTFryzdfVq1dx+PBhuN1uAMCOHTswOTkJABgaGkJpaSlKSkoAAG63G7W1tTh9+rTcPhAIIBQKyW2npqbQ1tYGl8sFl8uF0tJSDA8PW/blcrkAAG+88QYGBgYAABs2bEAqlUI0GkU6ncbbb7+NmpoauR8iWr0YfBHRmjY1NWV5bQQyjx49sqyfr/v376urpAcPHqirUFRUNOs2s7l//z46Ozuh6zp0XbfMepWUlODatWu4evUqfD4fgsGgujkRrVIMvohoTXM4HJbXxnVRGzZssKyfr40bN6qrpKKiInUVHjx4MOs2s9m4cSOOHz+OWCwmFyEEysvLkU6nsWnTJkSjUUxOTmLPnj1obGxUiyCiVYjBFxGtaeppv7NnzyIQCMhTgx6PB3/4wx+A3IzSxYsXZV4j/eHDh/L166+/js7OTvnzE8lkUl6YX1lZiZGREXlKM51Oo7e313LacyEOHjyIrq4uGTAa+8pmsxgaGkJdXZ3Mmy/wI6LVicEXEa1px44dk3cLapqGsbExfPLJJzK9tbUV77zzDjRNw4kTJ1BVVWXZ/sSJEzhw4IAMsEKhEA4fPgyfzwdN01BdXY2+vj4gd43Xxx9/jOrqamiahqqqKpw4cWLRP1OxY8cO7NmzB5s3b7bsy+VyoaamBi+99BK8Xi/8fj+6uroQDofVIohoFeLvfBGtMPafwmFbEi0O+469OPNFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZKOCBF/PPPMMAODbb79Vk4hoFkafMfoQLQ3HIqKF4zhkv4IEX5s2bQJyzzUjovkz+ozRh2hpOBYRLRzHIfsVJPh6+eWXAQATExNqEhHNwugzRh+ipeFYRLRwHIfsV5Dga+fOnQCACxcu4PHjx2oyEeXx+PFjXLhwATD1IVoajkVEC8NxaGUUJPjSdR3btm3D3bt3cezYMTWZiPKor6/H3bt3sW3bNui6ribTInAsIloYjkMroyCPFwKAL774Alu2bAEAXLt2Da+99pqahYhyPv30U+zatQsAMDY2hhdffFHNQovEsYhofjgOrZyCzHwBwIsvvigf6lpdXY1PP/1UzUJEuQGvuroaABAOhzngFRjHIqK5cRxaWQWb+TIEAgEMDg4CAH7yk5/g1KlTeOqpp9RsROvO48ePcezYMbS2tgIAqqqqMDAwoGajAuFYRDQdx6HVoeDBFwBEIhE0NjYCAJ577jns3bsXXq8XlZWV+O53v6tmJ1qzvv32WwwNDWFiYgIXLlzA3bt3gdw3zYaGBjU7FRjHIiKOQ6uSWCZjY2Ni27ZtAgAXLlxyy7Zt28TY2JjaXWgZcSziwsW6cBxaecsy82UWi8Vw/fp1DA8P45tvvsGf/vQnNQvRmvXMM89g06ZNePnll7Fz507eTbSCOBbResVxaPVZ9uCLiIiIiP6iYHc7EhEREdHcGHwRERER2YjBFxEREZGNGHwRERER2YjBFxEREZGNGHwRERER2YjBFxEREZGNGHwRERER2YjBFxEREZGNGHwRERER2YjBFxEREZGNGHwRERER2WjZH6wdi8Vw/fp1DA8P45tvvsGf/vQnNQvRmvXMM89g06ZNePnll7Fz507ouq5mIZtwLKL1iuPQKiSWydjYmNi2bZsAwIULl9yybds2MTY2pnYXWkYci7hwsS4ch1bessx8RSIRNDY2AgCee+457N27F16vF5WVlfjud7+rZidas7799lsMDQ1hYmICFy5cwN27dwEA4XAYDQ0NanYqMI5FRByHVqOCB1+BQACDg4MAgKNHj+LDDz/EU089pWYjWnceP36M+vp6/OY3vwEAVFVVYWBgQM1GBcKxiGg6jkOrQ0EvuI9EIhgcHMR3vvMdXLt2Db/+9a852BHlPPXUU2htbcW1a9fwne98B4ODg4hEImo2KgCORUT5cRxaHQo28/XFF19gy5YtAIBr167htddeU7MQUc6nn36KXbt2AQDGxsbw4osvqllokTgWEc0Px6GVU7CZr/r6egDAT37yEw52RHN47bXXcPToUcDUd6gwOBYRzQ/HoZVTkJmvWCyGV155Bc899xy+/PJLTu8TzcPjx4/x/PPP4+7du/jss894+3cBcCwiWhiOQyujIDNf169fBwDs3buXgx3RPD311FPYu3cvYOpDtDQcixYunU4jnU6rq22VzWaRTCbV1WQDjkMroyDB1/DwMADA6/WqSUQ0C6PPGH2IlmamsSidTiMUCsHpdELTNHi9XkQiEWSzWUu+9SASiViCrebmZly6dMmSx26XLl2SPwmyVIlEAtFoVF29ZNFoFIlEQl29IGrbrxYch+xXkODrm2++AQBUVlaqSUQ0C6PPGH2IlibfWJROp+Hz+eDxeDA6OgohBC5fvoyLFy9i//79pq3Xh8bGRsvnLRqNLvq3npLJJEKhkLp6wWpqahCLxdTVizI8PIzu7m519ZJ1d3cvOThR23614Di0ApQfXV0U41dziWjh2H8KJ19b1tbWimAwaFknhBCpVEoEAgGRSqWEEEIEAgHR3NwsAoGACAQCQgghxsfHRSAQEACEw+EQzc3Ncvt4PD5tX4FAQITDYSGEEOFwWJZpbG+kqcz7BiA8Ho8YHx8X4XBYOBwOAcCyrVqvnp4eS3nm7QKBgMhkMkKY2sdYL5Q6G8fU09MjPB6PJZ8QQmQyGREIBITP5xMej0d4PB4Rj8dlugGAaG9vt5QxPj6eNz0cDsu2MqjHl6/de3p6hMPhsOw/HA5bjtFI6+vrk3XxeDzT2sswPj6eN59RF2MxNDc3C4fDITwej/D5fLMeo3l787GuFuqx0fIqSEvzTSNaPPafwsnXlg6HQ/T19VnW5RMIBKb9M/f5fKK9vV0IU+ChBipm5nTjH67xD3x8fHxa+QZj38Y/b+OfurFvdV8ej8dSL3MQZARORsDV3t5u+WcPU1AiZgi+amtrRSaTEZlMxtJ+tbW1liDQ5/PlDWQACJ/PJ+tQW1s7rQ4+n08GvmrwNZ92N+qoUstKpVKWtjVez/Q+GMeaSqUEAEtwbj72+bSz+RiNdfn2uxrk6zu0fApy2pGIaLWamprC008/LV8nEglEIhG5mK/jaWpqQnl5OZA7pTY6OoqamhoAgMvlwtGjR/H+++/L/HMJBALytFxJSQlCodCMp66amppQUlICAHjllVdQWloq923UKZFIIJlMIpVKWeoVDAZluVevXsXhw4fhcrkAAG+88caCf8G8ra0NLpcLLpcLpaWl+PLLL9Usczp16pSsw9tvvz2tDqdOnYLb7baswwLa3ajjXIaGhlBaWirb1u12o7a2FqdPn1azYuPGjTh37hwSiQTcbjfi8TiKiorUbACA0tJSXL58WdahqKho3sdIxOCLiNY0h8OBhw8fqqsBAJ2dnfjDH/6grgYAPHr0SF2Fp59+GlNTU+rqefvbv/1bddWCGfXSdV0uvb29uHHjBgDg/v376OzslGnGdW1LvVgcuWuzGhsb4ff74fV6UVVVNa9rvhYSgBS63R88eKCuQlFREe7fv6+uxkcffYQtW7agvr4eTqcTn3322YwB3qNHj3Dy5En4/X6EQiF8/vnnahaiGTH4IqI1LRQK4dy5c/J1eXk5Ghoa8Oabb2JychL/63/9L0t+w4YNG9RVePjwIRwOh7p63v74xz+qqxZsw4YNcDgciMVicpmYmJAXrG/cuBHHjx+3pAsh5OzZUpw8eRI9PT24ffs2JiYm8Itf/ELNktdC7vArdLvnm7l68OABNm7cqK7GV199hYaGBty+fRujo6Po7e2dMWg9efIktmzZgtu3byMajeIHP/iBmoVoRgy+iGhNe/vttzE4OIiWlhYZBCSTSfz4xz+2nI5SlZSUwOfzoaOjA8j9FtW5c+fQ1NQEANi0aROQKwu5uwZHRkZMJQADAwPyn3cymUQ0GsXLL79sybNQJSUl8Hg8lp9TCIVCaGlpAQAcPHgQXV1d8mc0kskkNE2Trz0ez4wzgXM5cuQI9u3bB03T5E92GO2jOn36tNznBx98gEAgoGbJa652n8uzzz5r+QmRyspKjIyMyPcpnU6jt7cXR44cMW3133bt2iXfLzVoc7vdllk088xZNpvNexpTtZS2p7WFwRcRrWlutxujo6NIpVLw+XzQNA0VFRXweDz45JNP1OwWXV1duHLlCjRNw+bNm+HxeOTPMrjdboTDYbzwwgvQNA3/+Z//idLSUsv2Pp8P58+fl/tsa2sryAxUV1cXuru7ZRDkdDpx7NgxAMCOHTuwZ88ebN68GZqmobq6Gn19ffL02YkTJ3DgwAFomqaUOrf6+nqMj48jd7MWLl++jB/96EdqNiAXaJSVlUHTNKTT6Tnb2my2dp9LZWUlXC4XNE1DJBKB2+3Gxx9/jOrqamiahqqqKpw4cSLv+3Dz5k3U19fD7/ejrKwMwWBQ5qupqUFvby80TUMikUA4HEZnZyc0TcP+/ftRUVGhFjfNUtqe1paCPF7I+CAVoCiidYf9p3BWU1tGIhHcuHGjYL9ftRo4nU7cvHlTzhYmk0lUVFRgcnLSkk/TNMTj8bwBDq1Oq6nvrAec+SIionn5+OOPcejQIfj9fvj9fhw6dAg3b95UsxHRHDjzRbTC2H8Kh21JtDjsO/bizBcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EdGaFolEoOUeQG1eEomEmnUaXdcRiUTk6/lut9olEglEo1F19bJQ25CIGHwR0ToQCAQghLAs6/mhz8PDw+ju7lZXE5FNGHwR0brW398Pr9cLTdPg9XoXNCM007YtLS2oq6uT+To6OqBpGtLptFynvkaeWaJEIiGfuYfcNh0dHXKfuq4jmUzKdLNoNAqv1ysXo26RSASNjY0YGBiYcSYvEonA6XTKfWSzWZlm1MHv98vjNh+HsV9N01BXV2fZloj+G4MvIlq30uk0Dhw4gMuXL0MIgcHBQdTV1eUNSFSzbbt3715LEHflyhV4PB6MjIwAuaDN5/PB7XabSpyfrq4u3Lp1C0IIuN1uNDY2qlmQTqexb98+XL58GRMTE7h8+TL27dsHAGhoaEA4HJazgeoMYDQaRWdnJ+7duwchBHbv3o39+/db8nR1daG3txdCCHi9Xpw9exYw7be7uxtCCPzgBz9AKpWybEtEDL6IaB0wZnmMRdd1AMDQ0BBKS0tRUlICAHC73aitrcXp06eVEqabbVtjnTErNTIyghMnTuDq1asAgN///vfYs2ePqbT5O3XqFFwuFwDg7bffxsDAgJoFRUVFiMfjsh4bNmwAcjNpc7l69SoOHz4s9/HGG29M28epU6dk4Lh9+3bcuXMHAHDp0iUEAgEZ0JWXl6O0tNSyLREx+CKidUC95isWiwEAHjx4oGZFUVER7t+/r66eZq5tQ6EQBgYG0N/fj6qqKlRWVmJwcBAAMDg4iEAgoGy9cLPNnJ0/fx5+vx+6ruPSpUtq8ozu37+Pzs5O6LoOXdflrNd8Ajcimh8GX0S0bhUVFamr8ODBA2zcuFFdPc1c2+7cuRMXL17E73//e7z++utwuVzweDyIRqOYmpqSs1JLoV4zZrh06RLS6TRu376NWCyGhoYGNcuMNm7ciOPHjyMWi8kl3+lJIlo8Bl9EtG5VVlZiZGREnh5Mp9Po7e3FkSNHgFwgYp7hcjgcePjw4by23bFjB0ZHR9Hb2ytPve3ZswfvvvsugsGgLNPM7XZjbGwMyJWX7/Tn6dOn5UXsH3zwQd4ZNHVWTv2ph2effXbGC+EPHjyIrq4umZ5MJqFp2oz5zYxTlEabJBIJeZ0bEf0Fgy8iWrfcbjc+/vhjVFdXQ9M0VFVV4cSJE3KW5+DBgzhz5oy8RqypqQmvvvoqIpHInNsCQDAYhMPhkKcHA4EAUqkU/u7v/k7mMXv77bcxOjoqy6uoqFCzwOPxoKysTN4t+cknn6hZ8OabbwK5OxO9Xi+ef/55S3plZSVcLhc0TZsWmO3YsQN79uzB5s2boWkaqqur0dfXJ68Bm43b7UZPTw8qKiqgaRrOnz+PUCikZiNa9zQhhFBXLpSWuxW6AEURrTvsP4Wz1ttS0zTE43GeAqSCW+t9Z7XhzBcRERGRjTjzRbTC2H8Kh21JtDjsO/bizBcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8KZbz+WXLWfaTKpvNyl/DJiIiWg/WTfCVSCSgzfCIDK/Xi46ODiSTSezatStvnqVazrJnEolEoGnatGU1BYGXLl1CY2OjupqIiGjNWle/8+X1enHixAnL4y6SySReeOEFpFIp+QiQtSISieDGjRuIxWJqEq0iT0r/eRKwLYkWh33HXutm5gu556x1d3db1l24cAHBYBBut1vOjhmy2Szq6urkjJGu65ZTZC0tLXA6nfB6vfD7/ZY0TdPQ0dEBr9eLSCQyrexkMgld16FpGpxOJ1paWmSamhcAdF2Xz2DLZrMzbjtfHR0d8Pv98nVdXZ0sR9d1tLS0yH14vV709/fLvGrdo9GoTDNvazwPb7b8kUhE5jOOOxqNwuv1yjY3i0QicDqdeevV398vt/N6vTydSbTCeFkB0QxEAQAQBSpqWaVSKQFApFIpuc7j8Yienh4hhBDxeNxyHLW1tSIYDIpMJiOEEKK5uVkEg0EhhBA9PT3C4/HItPb2dhEIBOS2AITP55P7Usv2+Xyivb1dCCFEJpMRgUBAhMPhvHmFEJb0cDgsmpub5bY+n08eg1k4HLbUSRUIBER7e7uIx+OWYwkEAsLhcIjx8XEhcsfqcDhkusfjsdTd4/GIeDxu2dZ4PVd+cx2N466trRWZTEZkMhnhcDhEX1+fEKY2N9q0r69POBwOIUzvrVHn8fFxS51Xsyel/zwJ7GjLufqVWTwez9s316qenh5L31fHxeWk7psWxo6+Q3+xrk47AoDf78ehQ4dQU1ODRCKBXbt2YXJyEsjNvGzdulUeh9PpxLVr1/I+xDadTuPRo0coKSkBAESjUezbt09uqykPwDWXbZzqNLdXf38/Dhw4gMnJyWn1QG5Gafv27WhoaEBHRwe6urrwr//6rygrK8PXX3+NDRs2TDttGolE8l5PZZSbTqfh8/ng8Xhw6tQpWVfzvgxerxfd3d3YsGHDtLq3tLSgqKgIDQ0N07bNd6zm/OZTo3MddygUwpYtWyz1MnR0dODKlSuWU6x+v99yXKuV0X+MzxItnjHLspxj0UJO5y8k71qg9n87reS+14In6f/4mqBGY4vxJEXM7e3twufzCZGb2aqtrZVp6owTgBm/SY2Pj4tgMCh8Pp8IBoOitrZ21m3NZav7UdflSzfPfInct7xAICAAWGbnzObzDd2YqVLXmfdlrIvH47JugUBALh6PR+5H3Xau/PlmvszM5allm4XDYeFwOCz7cTgcM+ZfTYz+w6Vwi5n6uVE/Z4FAQDQ3N4tArj95PB452ypyfd3n8wnkPsfBYFB+ZoVpRtZYjJmucDhsqZMxHvT19QmPxyP3ZczWGvsyp800a6aWYc5n9Knm5mbhcDgEgBn7AQDR3t4uywoEAtPq4/P5hMfjEQ6HQ864C2U/xrbqe6COQXPtb6a2FKb3KRgMCgCWWfF8+zbOKBh5zXWn6cxtR8uvIC39JL1pmUxGIHfq0XxqTeQZlNXTZ2bBYHDWAR2zBF/j4+PT2st8Ck0tSyj/QMbHx2WwlclkptXFoA58qr6+Phk8mrdX/1mJ3KnDeDwuT+fNRN12rvzmOs513Go9zdrb2+Up4SeN0X/Gx8e5LHHJNxapn0n1cxaYx2l2Y/tUKiV8Pp/8zOY73W0uW+2D+fKb9xUIBGRAke8yCWO9ub7Ga2O8CeeCPuNUv3G8xj7MkLs8wkirra211NczxyUD5v2IPG2tHv9s+8vXNvneJ/P+jS/SRrq67/lcnkH/LV/foeVTkJZ+0t40Y8bK4/FY1quDsnrNl/n6BXNHz+QCIPO2mCX4Enmu+TIHFuogZPwzmCkIUV8b1IHPLJO7nmo8F8iZB/NAbnbKGPTVf0bqIBYMBuUgpw6AYo785jqqbSSU8oxvxUa9zINzKpUSHtMsgvGPwjyDsVo9af1nNcvXlupnUv2cqenC9GVDzSuUz2wmk7H0c6PvmgMEcx/Mdw2Uz+eT+YPBoAgGg/J1PB6fFjTlK8N8Paq6T5FnPJppvVF/g3n/RgBjtFW+/ahtqeaZbX9ztaVatvreqOnGWY6+vj6RyWTE+Pj4tECW/iJf36Hls67udjQcPHgQo6OjOH78uJpk8fOf/xxOpxPFxcXQNA1XrlxBOBwGAITDYXR2dkLTNOzfvx8VFRXq5rPq6urClStXoGkaNm/eDI/HI69VcLvdCIfDeOGFF6BpGv7zP/8TpaWlctuPPvoIY2Nj8Hq98Hq9AIA333xTppsNDAxAy/M7Xx9++CFqa2tRUlICl8uFkydP4tChQ3I7n88n7/R89913cfPmTbhcLiBX9+7ublme0+nEsWPHTHu1Wmj+mYRCIRw+fBg+nw+apqG6uhp9fX1Ars1aW1tRXV0t2/Tw4cPYsWOHWgzRnIx+NR/nz5+H3++Hruu4dOmSmmzx4MEDjIyMyLuBdV1HKpXC8PAwkOvbW7ZsQX19PZxOJz777DPZ78xlqIqKinD//n119YKp140ODw/Len744YeYmpqypC+Vur+FtOVcampq8NZbb6G1tRXFxcU4efIkioqK1GxEK0ONxhaDEfPaon6DpOXF/lM4+dpS/TzPNWMiFjDzlW8Wyjxbo878zHV6XJ35MZ/mM+Tb53LMfKmnRIXSVvn2o7almme2/eU7LnN+tWz1vVHTjVl9kefsAk2Xr+/Q8lmXM19EtH643W6MjY0BuTt8T58+rWZBZ2cn0uk0kLtzeXJyEt/73vdQXl4Oj8eDjo4OILf9xYsX5XbqLJTxW3yGZ5991vJUi8rKSoyOjsq7MrPZrOX36nbt2iWfQDHTLE1lZSVGRkZkGel0Gr29vThy5IiadV5Onz4t6/jBBx8gEAgAAB49emTJ19/fj5GREcs6ldvtntYmqpn2p26ntuVc1H2fPHkSZ8+eBYBps4dEK43BF00Ti8V4uzatGW+//TZGR0ehaRqqqqryXiIw22n2y5cv49/+7d+gaRrq6uqwZ88euZ1xul/L/bDv888/L9OQC5RcLhc0TUMkEpnz9PjNmzdRX18Pv9+PsrIyBIPBaT+V4na78fHHH8syqqqqcOLEiWn55svj8aCsrAyapiGdTuOTTz4BAJSXl6O2thbFxcVwOp348ssvLZc/5FNTU4Pe3l55eUM+M+1vrraci7rvhVyeQWS3dfc7X0SrDftP4SymLdfz70Npyu8RLje790fzt5i+Q4vHmS8iIiIiG3Hmi2iFsf8UDtuSaHHYd+zFmS8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IqI1LZ1Oy9/wIiJaDRh8EdGa1tzcvORH1awn6XR6wT9wSkQLw7sdiVYY+0/hsC2XLpFIYOvWrWzDdYZ9x16c+SKiNU3XdTmTk0gkoGkaotEonE4nNE1DS0sLkskkdF2Hlvt1deM0ZSQSga7raGlpgZZ7KLx5VkhNB2Apy+l0oqWlBcg9SkjL/aq7IZFIyF9fz2az8lf2jXoZ1P04nU5Eo1H09/fD6/VC0zToui7zG9sYx6jrunykj7kN1G2NwAu5f8acASNaHgy+iGjd+fzzzzE5OYlMJoNf/vKXaGxsRFtbG4QQ8Hq9ltOUAwMD+P73vw8hBG7evIn333/f8uicgYEBPPvss3LG4NChQ9i9ezeEELh37x7u3LmDSCQCl8uFYDCIoaEhue358+cRDAYBAD/96U8xOTkJIQSEEEilUpbgx1yPjz/+GHV1dbh+/Tpu3bqFTCaDkZERWa9oNIrOzk7cu3cPQgjs3r0b+/fvl2Uh1wbmbfv7+1FeXo54PA7kZkDW46/+E9mBwRcRrTttbW1A7oHLgUAA7777LtxuNwBg+/btuHHjhswbCAQQCoUAACUlJQiFQhgeHrak19TUALlZr9HRUfna5XLh6NGjeP/99wEAr7/+Orq6uuS20WgUe/fulX+bH4598ODBGeuxY8cOTE1Noa2tDS6XCy6XC6WlpbJeV69exeHDh+XzKd944w0MDAzIspBrA/O2X375pSWdiJYPgy8iogX427/9W3WV9OjRI3UVnn76aUxNTQEAQqEQUqkU0uk0+vv74fF4UFJSAgCYmppCfX09dF2Hrut47733pgVM83X//n10dnbKsoxZr5kedk1E9mLwRUS0AH/84x/VVdKGDRvUVXj48CEcDod8HQqFMDQ0hOvXr+PQoUNyvcPhQFdXF2KxGGKxGG7fvr3oi583btyI48ePy7JisRiEEHygNdEqweCLiGgWAwMDcsYomUwiGo3i5ZdfVrMBudOSPp8PHR0dQO4i+nPnzqGpqUnmqampQVdXF6LRKCorK+X62tpauR0AdHR0wO/3y9cLcfDgQXR1dcmL7JPJJDRNk69ns2nTJiBXdyJaHgy+iIhm4fP5cP78eWiahoqKCrS1tc06g9TV1YUrV65A0zRs3rwZHo/HcuF6SUkJpqamUFpaKq8zA4Bjx44BubsMNU3DlStXLNeHLcSOHTuwZ88ebN68GZqmobq6Gn19ffIasNm43W40NzejuLh42h2URFQY/J0vohXG/lM4hW7LSCSCGzduIBaLqUlEa0qh+w7NjjNfRERERDbizBfRCmP/KRy2JdHisO/YizNfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERkkUwm+WBtomXE4IuIaJWIRqNIJBLqattVVFTgq6++UlcDABKJhPw19MXQNC3vMabTaXi93hnTidYSBl9ERKtEd3c3hoeH1dW2m5ycRHl5ubp6WQ0NDcHr9UIIYfu+iezG4IuI1rRkMilnVLxeL6LRqExTZ1kikQh0Xbekd3R0yO11XUcymQRMM0DRaBROpxOapqGurs5yuq6/v3/Gfeu6jpaWFui6LpeBgQE0NjbmnVky6tbS0gJN0+B0OhGJRGS6Wh5yx67ruszf0tICAMhms9A0Del0Wm6fSCTg9XoBpV2y2SxCoZA8hs8++0xuY6TX1dVB0zRomib3YWhpaYHT6ZxWX7NIJIIf/ehHGBgYkPtWjxd59hUKhWR753s/WlpaLG3g9Xotx2zIt636XkYiEZmm6/qs77PxGcEM74t5P36/35Kf1gcGX0S0pjU2NqK1tRVCCAwODmLfvn15/wHPpKurC7du3YIQAm63G42NjZb0zz//HJOTk8hkMrh9+zbOnj0L5E6jHThwAJcvX5b7rqurswR7Z86cwbvvvotYLIZYLIZAIIBwODzjw40HBgbw/e9/H0II3Lx5E++///6M5QHAoUOHsHv3bgghcO/ePdy5cweRSAQulwvBYBBDQ0Ny2/PnzyMYDMrXhp/+9KcAgEwmg1u3bmFqampa+uTkJIQQEEIglUrJICsajaK3txejo6OYnJxEUVGRZVtDQ0MDwuEwAoGAZeZrYGAAzz77rGyPDz/80LIvj8eD/fv3W8oyvx+//OUv0djYiLa2Nggh4PV6cenSJUt+s5ney2g0is7OTty7dw9CCOzevVvuN51O49VXX5Xv8+XLl1FRUWEJztT3Zd++fbKst956C9XV1TIvrROiAACIAhVFtO6w/xROvrYMBoMiGAyKeDwuhBAiHo+LTCYj8xvrhRAiHA6LQCAgX6vpqVRKlh+Px6ftq6enR27f3t5uKUsIIZqbm0UwGBRCCBEIBEQ4HLak51tnUOsmhBC1tbUyv7rt+Pj4tPr19fUJh8MhRK6uPp9PpjkcDjE+Pi6EctxqG6jH7XA4LOl9fX2ynmqdRJ7yDOrxqa9Fnn1lMhkBQIyPj0+rl8jtf7b315BvW/N7GQwGLcdh7FfM8D77fD6533xt4HA4RDgcFuPj4yKTyeRtD7vl6zu0fDjzRURr2kcffYQtW7agvr4eTqcTn332GVwul5ptXtxut7rK4m/+5m/k3w8ePLCkAUBRURHu37+vrl60v/3bv1VXSY8ePVJX4emnn5YzV6FQCKlUCul0Gv39/fB4PCgpKVE3mdPU1BTq6+vlabX33nsPAwMDaraCUGfdjPcx37Eulfm9vH//Pjo7O+UxGrNeiUQCDx48wMjIiEzTdR2pVGrWa/dGR0fxxz/+EdXV1SgrK8PXX3+tZqE1jsEXEa1pX331FRoaGnD79m2Mjo6it7d30XfTzXW60vxPNN8ptgcPHmDjxo3q6kX74x//qK6SNmzYoK7Cw4cP4XA45OtQKIShoSFcv34dhw4dsuSdL4fDga6uLnnq9Pbt2zBOExaaue7IXQOGGY51qczv5caNG3H8+HF5jLFYDCJ3erSoqAhVVVWWtMnJSTQ0NFjKM2SzWTx69AhtbW2YmJhAd3c39u3bp2ajNa4gwdczzzwDAPj222/VJCKahdFnjD5ES5NvLNq1a5cMttSAyOPx4A9/+AOQm8W4ePGiJR0ATp8+Lf/Jf/DBBwgEApZ04/qmbDaLX/3qV9i+fTsAoLKyEiMjI/Ji6nQ6jd7eXhw5csSyvZnb7c47Y2YYGBiQx5JMJhGNRvHyyy+r2QAAJSUl8Pl86OjoAHL1O3fuHJqammSempoadHV1IRqNorKy0rT1X9TW1uL06dNArozz589PSzf2AQAdHR3w+/0AgB/+8Ifo7OyU7WfOtxjmugDA2bNnEQgEFjVjl89M7+XBgwfR1dUljyOZTELTNGSzWVRWVmJ0dFS+z9lsFl6vF/39/aaS/+Lrr7+2XBO2HIHjQnEcsl9Bgq9NmzYBuVuFiWj+jD5j9CFamnxj0c2bN1FfXw+/34+ysjIEg0F5QXdrayveeecdaJqGEydOoKqqSm5n8Hg8KCsrg5a7O/CTTz5Rs8DpdKK4uBhVVVVyxsPtduPjjz9GdXU1NE1DVVUVTpw4MevPKNTU1KC3t1fe8afy+Xw4f/48NE1DRUUF2traZi2vq6sLV65cgaZp2Lx5Mzwej2VGpqSkBFNTUygtLZ3xlOrPf/5z3L9/H5qmoaysDH//939vST927BiQu0NS0zRcuXIFXV1dQG5mLRgMori4GE6nEw8ePIDP57NsvxDHjh2TdwlqmoaxsbG878dS5Hsvd+zYgT179mDz5s3QNA3V1dXo6+uDy+WC2+1Ga2urfJ83b96Mw4cPY8eOHWrRQK7N29raUFZWBl3XUV1djZ6eHjWbrTgOrQD1IrDF+PGPfywAiH/5l39Rk4hoFv/yL/8iAIgf//jHahItQqHHopkuDhczXKS9nGa6WJyWzu73crXhOGS/gsx87dy5EwBw4cIFPH78WE0mojweP36MCxcuAKY+REvDsYhoYTgOrQxNFOjKyH/4h3/A7373Oxw9ehS//vWv1WQiUhw9ehS/+c1vsG3bNvzv//2/1WRaJI5FRPPHcWhlFCz4+uKLL7BlyxYAwLVr1/Daa6+pWYgo59NPP8WuXbsAAGNjY3jxxRfVLLRIHIuI5ofj0MopyGlHAHjxxRcRDocBANXV1fj000/VLESUG/CMX7QOh8Mc8AqMYxHR3DgOrayCzXwZAoEABgcHAQA/+clPcOrUKTz11FNqNqJ15/Hjxzh27BhaW1sBAFVVVcv2Y5TEsYgoH45Dq0PBgy/kfivFeP7Zc889h71798Lr9aKyshLf/e531exEa9a3336LoaEhTExM4MKFC7h79y6Q+6Y5048wUuFwLCLiOLQqKXc/FszY2JjYtm2bfF4UFy5cILZt2ybGxsbU7kLLiGMRFy7WhePQyluWmS+zWCyG69evY3h4GN988w3+9Kc/qVmI1qxnnnkGmzZtwssvv4ydO3dC13U1C9mEYxGtVxyHVp9lD76IiIiI6C8KdrcjEREREc2NwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdmIwRcRERGRjRh8EREREdlIE0IIdWUh/cd//Af6+vpw69YtfPPNN8hkMmoWojWruLgYmzZtQllZGV599VX80z/9k5qFbMKxiNYrjkOrkFgmiURC+P1+AYALFy65xe/3i3g8rnYXWkYci7hwsS4ch1bessx8/exnP8O//uu/AgBeeukl/PM//zM2b96Mbdu24a//+q/V7ERr1p///Gf87ne/w7179/Dv//7vuHPnDgDgvffew89+9jM1OxUYxyIijkOrUcGDr61btyKRSAAAmpqacPLkSTUL0br1zjvv4P333wcAlJeXIx6Pq1moQDgWEeXHcWjlFfSC+5/97GdIJBL4q7/6K/z2t7/lYEekOHnyJH7729/ir/7qr5BIJPitc5lwLCKaGcehlVewma9EIoGtW7cCAH77299i+/btahYiyrlx4wb+8R//Ecj1nb/7u79Ts9AicSwimh+OQyunYDNfx44dA3LT+xzsiGa3fft2NDU1AQDq6+vVZFoCjkVE88NxaOUUZObrP/7jP/D666/jpZdewujoqJpMRDPw+Xy4c+cOrl69ytu/C4BjEdHCcRyyX0Fmvvr6+gAA//zP/6wmEdEsjD5j9CFaGo5FRAvHcch+BQm+bt26BQDYvHmzmkREszD6jNGHaGk4FhEtHMch+xXktOP/+B//A5lMBn/605/42zlEC/DnP/8ZzzzzDIqLi/H//t//U5NpgTgWES0cxyH7FST40jQNAFCAoojWHfafwmFbEi0O+469CnLakYiIiIjmh8EXERERkY0YfBERERHZiMEXERERkY0YfBERERHZiMEXERERkY0YfBERERHZiMEXERERkY0YfBERERHZiMEXERERkY0YfBERERHZiMEXERERkY0YfBERERHZiMEXEVGBpNNppNNpdTURkQWDLyKiRYpEIpZgq7m5GZcuXbLkWYr+/n44nU5omqYmLVkkEoGu6/K1pmlIJBKWPIWg7oeIGHwRES1aY2MjvvnmG/k6Go2ioaHBkmcpzp07h6amJggh1CQieoIx+CKiNU3XdbS0tEDXdWiaBq/Xi/7+fpmezWZRV1cHTdOgaRpCoRCy2axMj0ajcvbJ7/cjmUwCuZkiANi6dauc2dF1HZFIBP39/fB6vbIM5GaA6urqAADJZFLWx+l0IhqNWvIiV1Zvby8aGxvlvtS6trS0WLYx9mscp1FX5Pbp9/uhaRp0XcfY2JhlWwD4wx/+ILfXdd2yfTQahdfrlYu5zmq91G3N6urqZDsQrVcMvohozTtz5gzC4TCEEDhx4gQOHDggA6wPP/wQk5OTEEJACAGPx4P9+/fLbfft24d79+5BCIG33noL1dXVACBno+LxOGKxmMwPADt27MDk5KQlAOns7MTOnTsBANXV1di9ezeEELh37x7efffdaaf8YrEYAoGArDcA/PSnP7XUNZVKIRKJALnrzV599VVcvnwZQghcvnwZFRUV8jirq6uxZ88eCCHQ1taGVCpl2R8AdHV14datWxBCwO12o7GxEciVvW/fPly+fBkTExO4fPky9u3bJ7cz6pXJZCCEwEsvvYSTJ0+aSv5vdXV1mJycRFtbm5pEtL6IAgAgClQU0brD/lM4+doyEAiIcDhsWefxeEQ8HhdCCOFwOOTfQgiRyWQEADE+Pi7Tw+GwGB8fF5lMxpIXgOW1eV+1tbWiublZCCHE+Pi4cDgc8m+1js3NzdPqKPLUXa1rX1+fCAQCQggh2tvb5d8Gn88n4vG4iMfj0/YZDoct+dVjSaVSchv1uI20mdrQzNhPc3Oz8Pl8IpPJqFloFcjXd2j5cOaLiNYd8ynBqakpS5rL5QIAPHr0CAAwOjqKP/7xj6iurkZZWRm+/vprS/6Z1NTUoLe3FwBw4cIF1NbWAqZydV2XS29vL27cuGHZPp+pqSnU19fL7d577z0MDAwAAB48eICRkRFLualUCsPDw2ox8+J2uy2vz58/D7/fD13Xp91UoLahKpvN4syZM3jrrbdk+xKtZwy+iGjdmZiYkH87HA5LmnGabsOGDchms3j06BHa2towMTGB7u5uy+m22ZSUlAC5a616e3uxd+9eIFeuw+FALBaTy8TExLRTl/k4HA50dXXJ7W7fvi1PSRYVFaGqqspS7uTk5KJvADDfxXnp0iWk02ncvn0bsVhsWplqG6pcLheuXbuGurq6Ga8FI1pPGHwR0ZrX2dkpg4loNIrJyUl873vfAwDU1tbi9OnTMu/Zs2cRCARQUlKCr7/+2nLd1IYNG2Q+APB4PHj48KFlndnx48fldVNGMFZSUgKPx2O5YD0UCk27eD6f2tpadHR0yNcdHR3w+/0AgMrKSoyOjsrgJpvNypsLysvL4fF45LbpdBoXL16U5RhOnz4tj/WDDz5AIBAAcrNqZsZ1ZoZQKGTZtqOjQ96EYCgvL0dbWxsqKioYgNG6x+CLiNY8n88n78Z79913cfPmTXn669ixY/JuRk3TMDY2hk8++QTIBUptbW0oKyuDruuorq5GT0+PLNe4eN+4G1FVWVmJgYEBHD582LK+q6sL3d3dcp9OpxPHjh2z5MnHyGNsd+XKFXR1dQG504Stra2orq6GpmnYvHkzDh8+jB07dgAALl++jH/7t3+Dpmmoq6vDnj17LGUjF0yWlZVB0zSk02nZDm+++SaQ26/X68Xzzz9v2e7nP/85nE4niouLZb3C4bAlD3JBWlNTEw4dOmS5o5RovdGEMWe9BMbAU4CiiNYd9p/CydeWuq5j+/bt006VEdFf5Os7tHw480VERERkI858Ea0w9p/CYVsSLQ77jr0480VERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfZJt0Oo10Oq2uJnoiJBIJ+Svgi6FpGhKJhLqaFiEajbIt6YnG4GsG2WwWTqcT/f39ahLq6uoQCoXU1fOylAFY13VEIhF1NZAr17z4/f68dV9Jzc3NuHTpkrqaiJ5Q/f39aGlpUVcvu+7ubgwPD6uriZ4YDL5m4HK5EAqFcP36dTUJ0WgUr7/+urp6xcXjcQghIITAoUOH8Oqrr66qmaZoNIqGhgZ1NdGyaWlpQV1dnWWdruuIRqNALnjwer3QNA1erxfJZFLm0zQNHR0d8Hq9li890WgUTqcTmqahrq4O2WxWprW0tMDpdMLr9cLv91vKm00kEpFl6rouyzRm26LRqKynruszbuv1ei1fupLJJHRdh6ZpcDqdlkAp30ye+QteJBKBrutoaWmR+ZLJJLxeL3Rdh9frRWtrK/bu3Qso7WXUM51Oo66uTu7fXLfZ2t7YbygUmratrusYGBhAY2PjtPoTPTFEAQAQBSpqVenr6xMOh0NkMplp6wzj4+MiEAgIAMLhcIienh6ZFggERHNzswgEAiIQCAiRa6v29nbh8XgEABEIBMT4+LjcpqenR3g8Hrmo5YXDYfnaDICIx+Mzruvr65P79Hg8ln3mq2dPT49wOBwCgPD5fDJ/PB6f9l6b65XJZCzt0dzcnDefyFMn87GGw2FZL6MeMx37k26t9p+VoLbl+Pi4pb+mUikBQGQyGfm38dk28hr93fjsp1IpIUyf/draWiFyn3Wfzyc/l0bfNbZvb2+X/ckoT+2jYo7tzPvMZDIik8kIh8Mh+vr6LNsadVTHJ5/PJ9rb24Uw9U2jvnP15XA4LJAbrwwej0ceQyaTEQDkvo32Mo7D5/NZ8ht9Wpjeh5naPhAICIfDYdnW5/MJgzqW0NKpfYeWlyYK8Ahz49tHAYpadbxeL06cOCFPMxrfotva2mT68ePHUVNTg2w2i7KyMnR3d6O8vBy6rmNkZATXrl1DeXk5kGsrn8+HWCwGl8uFuro6pNNpxGIxpNNpeDwejI+Po6SkBMlkEi+88IJsV13XsX379ryzR5qmIR6Py/10dHTgRz/6EVKpFABMK7eiogL37t2Dy+WasZ6ZTAYulwvRaBTvvvsuJiYmkEgksHXrVst7ba5XJBLBgwcP8Itf/ALZbBa6ruOtt95CKBSy5Eun0/D5fLh58yZKSkrka6MOkUgEjY2NaG9vR01NjdyvUae1xOg/JSUlahItkDF7Yv58GjM0O3bsQEdHB27evIloNIqOjg5cuXIFsVhM5vX7/Th16hTKy8un9al8n/1oNIru7m7Zfx89eiTfx2g0in379sn8anmGUCiELVu2yH6dzWZRXFwMIUTefZr7kbqtmTp+IDfbdODAAUxOTs5ZdiQSwY0bNyzt4/V65fhm1DOVSsHtdk87PmMGzaibeX9ztb061ql1VdNp6dby//FVSY3GFmMtR8zNzc0iGAwKkfum53A4LN/W1ONubm6W38jyfTuD8u3X+AYocuXnSzPW5SvPYLwHxuLz+eS3Y/UbuMh9K52tXIfDIcLhsBgfH7fUa65vy+3t7XLfmUxGjI+Py2/Gaj61Tua2Nn9LNqhtt1ao7x2XpS9m7e3tcrbK3C/C4bBwOBwikJvxNWZbjM8olM9bvs9+PB6Xn9Px8XERDAaFz+cTwWBQ1NbWWvKr5RkCgYDweDyWehh58+3T3I/y9V1Dvm3N6/Klm8vL1wfb29sFcjP26my1enzhcNhSN/P+5mp79bjUuqrptHT5+g4tH17zNYe9e/eit7cX2WwWQ0NDcDqd8pvto0ePgNy3MGPp7e3FjRs3lFJm5na7La/Pnz8Pv98PXdcXfHG6+Zqv27dvY8eOHQCABw8eYGRkxFLPVCo16wWro6Oj+OMf/4jq6mqUlZXh66+/VrPkVVNTg7feegutra0oLi7GyZMnUVRUpGbDgwcP1FUoKirC/fv31dXrxvj4OJclLvlUVlYiGo0inU4jlUrJflFUVISqqirEYjG5TE5OLmg2xdwvTp48iS1btuD27duIRqP4wQ9+YMk7k40bN+L48eOWegghps2Q5bNx40Z1lbRhwwZ1FR4+fAiHw6Gunrd33nkHqVQKsVgMExMTi77xqBBtT/REU6OxxVjrEbPP5xM9PT0iGAxarn9QrydR5ft2pn47NM985ZsNMufPV55BLdesvb1dzijlo5ZrzFgZFvJt2ZgpE7lygsFg3m+z+Y51vc980dLN1JbBYFAEAgE5AyZyfc98/WMmkxEej0fOjKmfN+Ozb3yGM8o1X+bPt/HZN9fFfK2WWV9fn+VaKWNG3ZhxVo/HvB/1mi91Nl695svcH9XrrozrPI30fH0wnLsOzFjMM+hqe4Vnmfmaq+3VMUlth9raWsv1pLR0M/UdWh6c+ZqHQ4cO4Ve/+hV6e3tRWVkp15eUlMDj8cg7p5C7fmOuW69Pnz4t72b64IMPEAgEgDyzQerPSmzcuHFanvmorKzE6OiovB4mm81OuyvK7Ouvv0ZFRYWso/kb9KZNmwDTtTXRaBQjIyMy/eTJkzh79iyQu2N0JpWVlRgZGZHlpNNp9Pb24siRI2pWoiV7/fXXMTAwYJmNcrvdaG1tRXV1NTRNw+bNm3H48GE5MzYbp9OJ4uJiVFVVydmacDiMzs5OaJqG/fv3o6KiwrJNU1MTXn311Wn9eseOHdizZw82b94MTdNQXV2Nvr6+WfuPIRQK4fDhw/D5fJZtDV1dXbhy5Yo8Po/HI+vrdrsRDofxwgsvQNM0/Od//idKS0tNpVul02lcvHgRmUxGzrAfOnQIJ06cULPOaSltj9wMe29vL7Ql/HQP0YpSo7HFWOsRcyZ3V0++2aNx092OMN2VJPJ8exO5tmpubpZ3+QUCActMkVGW8S3Q/G3SuJNJ/TYq8nzrVJnvLDR/uxUz1NP4Rh3Ic22H+duvcZek+o3fk7tbMxgMztge87nb0WyuY3xSrfX+Yye25fIZHx8XHtNdmWIes+r05GDfsRfvdiRaYew/hcO2XF6RSASdnZ3wer2YmJiAz+fDRx99NK9ZOlrd2HfsxeCLaIWx/xQO25Jocdh37MVrvoiIiIhsxOCLiIiIyEYMvoiIiIhsxOCLiIiIyEYMvoiIiIhsxOCLiIiIyEYMvoiIiIhsxOCLiIiIyEYMvoiICiSdTiOdTqurlyyZTMpnrRLRk4/BFxHRIkUiEUuw1dzcjEuXLlnyLFQ6nZ728O2Kigp89dVXlnVE9OTi44WIVhj7T+HY3ZaapiEej6O8vFxNWrREIoGtW7fadgxEWIG+s95x5ouI1g1d19HS0gJd16FpGrxeL5LJJCKRCJxOJzRNs8w6JZNJmdfpdKKlpUWmGf+stm7dCl3XZfmRSATZbBaapllmxRKJBLxeL5Ar1+/3w+v1Wso1Ai+jfKMumqYhkUgAALLZLOrq6qBpGjRNQygUspyS1DQNHR0d8Pv98hiX41QoES0egy8iWlfOnDmDcDgMIQSCwSAqKipQVFSEyclJxONxNDY2yryHDh3C7t27IYTAvXv3cOfOHRkQGTME8XgcsVhMbgMALpcLwWAQQ0NDct358+cRDAYBANXV1Th06BAmJiZw79499Pb2IpFIoLy8HPF4HMiV39DQILc3fPjhh5icnIQQAkIIeDwe7N+/35Knq6sLvb29EELA6/Xi7NmzlnQiWlkMvohoXWlqakJJSQkA4JVXXkFpaSlqamoAQJ4+TCQSSCaTGB0dlWkulwtHjx7F+++/byptZq+//jq6urrk62g0ir179wIAuru78cYbb8g0h8OB4eFh+Xo2Z86cwZEjR+TrY8eOYWBgAMlkUq47deoU3G43AGD79u24c+eOTCOilcfgi4goj0ePHqmr8PTTT2NqakpdnVcoFEIqlUI6nUZ/fz88Ho8M+oaHh6HrOnRdx4cffjjvMgFMy+tyuYAZ6ktEqxODLyKiPDZs2KCuwsOHD+FwONTVMwqFQhgaGsL169dx6NAhIHe91/vvv49YLIZYLIZf/OIX8lqw+VD3b1zvla++RLQ6MfgiIsqjpKQEPp8PHR0dQC7IOXfuHJqammQej8eDhw8fmrayqqmpQVdXF6LRKCorK4E8M1T9/f0YGRmRrzdt2gSYgipVbW0tTp8+LV+fPXsWgUBAzqoR0erH4IuIaAZdXV24cuUKNE3D5s2b4fF4LBfBnzhxAgcOHJB3PqpKSkowNTWF0tJSeQ1WeXk5amtrUVxcDKfTiS+//BKlpaVyG7fbjebmZhQXF8u7KM2OHTsm78zUNA1jY2P45JNP1GxEtIrxd76IVhj7T+GwLYkWh33HXpz5IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGzH4IiIiIrIRgy8iIiIiGxUk+CouLgYA/PnPf1aTiGgWRp8x+hAtDcciooXjOGS/ggRfmzZtAgD87ne/U5OIaBZGnzH6EC0NxyKiheM4ZL+CBF9lZWUAgHv37qlJRDQLo88YfYiWhmMR0cJxHLJfQYKvV199FQDw7//+72oSEc3C6DNGH6Kl4VhEtHAch+xXkODrn/7pn+D3+3Hnzh288847ajIR5fHOO+/gzp078Pv9+Kd/+ic1mRaBYxHRwnAcWhmaEEKoKxfj97//PcrLywEAv/3tb7F9+3Y1CxHl3LhxA//4j/8IAIjH47Lv0NJxLCKaH45DK6cgM18A8Hd/93d47733gNzU5Y0bN9QsRJQb8Izp/ffee48DXoFxLCKaG8ehlVWwmS/D1q1bkUgkAABNTU04efKkmoVo3XrnnXfw/vvvAwDKy8sRj8fVLFQgHIuI8uM4tPIKHnwBwM9+9jP867/+KwDgpZdewj//8z9j8+bN2LZtG/76r/9azU60Zv35z3/G7373O9y7dw///u//jjt37gC5b5o/+9nP1OxUYByLiDgOrUpimcTjceH3+wUALly45Ba/3y8SiYTaXWgZcSziwsW6cBxaecsy82X2H//xH+jr68OtW7fwzTffIJPJqFmI1qzi4mJs2rQJZWVlePXVV3k30QriWETrFceh1WfZgy8iIiIi+ouC3e1IRERERHNj8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDZi8EVERERkIwZfRERERDbShBBCXVlIsVgM169fx/DwML755hv86U9/UrMQrVnPPPMMNm3ahJdffhk7d+6ErutqFrIJxyJarzgOrUJimYyNjYlt27YJAFy4cMkt27ZtE2NjY2p3oWXEsYgLF+vCcWjlLcvMVyQSQWNjIwDgueeew969e+H1elFZWYnvfve7anaiNevbb7/F0NAQJiYmcOHCBdy9excAEA6H0dDQoGanAuNYRMRxaDUqePAVCAQwODgIADh69Cg+/PBDPPXUU2o2onXn8ePHqK+vx29+8xsAQFVVFQYGBtRsVCAci4im4zi0OhT0gvtIJILBwUF85zvfwbVr1/DrX/+agx1RzlNPPYXW1lZcu3YN3/nOdzA4OIhIJKJmowLgWESUH8eh1aFgM19ffPEFtmzZAgC4du0aXnvtNTULEeV8+umn2LVrFwBgbGwML774opqFFoljEdH8cBxaOQWb+aqvrwcA/OQnP+FgRzSH1157DUePHgVMfYcKg2MR0fxwHFo5BZn5isVieOWVV/Dcc8/hyy+/5PQ+0Tw8fvwYzz//PO7evYvPPvuMt38XAMciooXhOLQyCjLzdf36dQDA3r17OdgRzdNTTz2FvXv3AqY+REvDsYhoYTgOrYyCBF/Dw8MAAK/XqyYR0SyMPmP0IVoajkVEC8dxyH4FCb6++eYbAEBlZaWaRESzMPqM0YdoaTgWES0cxyH7FeSaL03TAAAFKIpo3WH/KRy2JdHisO/YqyAzX0REREQ0Pwy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIiIiGzE4IuIiIjIRgy+iIhWqWw2i2Qyqa5edZLJJLLZrLqaiGbA4IuIaJWIRqNIJBLy9aVLl9DY2GjJsxpVVFTgq6++UlevSpFIBOl0Wl1NZCtNCCHUlQulaRoAoABFEa077D+F86S3pa7r2L59OxoaGtQkKhBN0xCPx1FeXq4mrWtPet950nDmi4jWtGQyCa/XC03T4PV6EY1GZZqmaZaZpkgkAl3XLekdHR1ye13X5WnARCIBTdMQjUbhdDqhaRrq6uosp9/6+/tn3Leu62hpaYGu63IZGBhAY2Oj/Edoro/f77dsn81m4XQ6kU6nkc1mUVdXB03ToGkaWlpaZD5VJBKR9dV1XdbXfDzm44XpONRy6urqAKUd1eNC7j3QdR2apsHpdFrqZxxjS0uLTI9Go5a2M78nxjb5jgGm98zv98t2N2a6jHbdunXrtDKJ7MTgi4jWtMbGRrS2tkIIgcHBQezbt29Bp526urpw69YtCCHgdrunnQb8/PPPMTk5iUwmg9u3b+Ps2bMAgHQ6jQMHDuDy5cty33V1dZZg78yZM3j33XcRi8UQi8UQCAQQDofzzj4cOnQIV69ela+Hhobg8Xjgdrvx05/+FJOTkxBCQAiBVCqFSCRi2R6505qdnZ24d+8ehBDYvXs39u/fb8nz+eef49atW8hkMhgZGUF/fz927NiByclJy/VnnZ2d2Llzp2Vbg/m4kKv77t27IYTAvXv3cOfOHUv9BgYG8P3vfx9CCHz88ceoq6vD9evXLfUw2m0+x9DV1YXe3l4IIeD1euV7YrRrPB6XdSNaCQy+iGhN27hxI86dO4dEIgG32414PI6ioiI124xOnToFl8sFAHj77bcxMDBgSW9rawMAuFwuvPXWW7hx4waQC45KS0tRUlICAHC73aitrcXp06fltk1NTfM+/VVZWYne3l45y3P16lUcOnQIyAUkR44ckXkPHjwo62F29epVHD58WB7PG2+8kfd4XC4XXC4XSktL8eWXXwIAQqEQLly4AORmsiYnJ7Fjxw7LtgbzcSWTSYyOjqKmpgbItdPRo0fx/vvvy/yBQAChUAgAsGPHDkxNTU2rx/DwMDDPYzh16hTcbjcAYPv27bhz544lnWilMfgiojXto48+wpYtW1BfXw+n04nPPvtM/uNeKOMf+kz+5m/+Rv794MEDSxoAFBUV4f79++rqeXG73QgGgxgaGkI2m0Vvby/eeOMNAMDU1BTq6+vlqb733ntvWkACAPfv30dnZ6fMZ8wYmWfjZlJTU4Pe3l4AwIULF1BbW6tmyevRo0fqKjz99NOYmppSV8/LUo6BaLVg8EVEa9pXX32FhoYG3L59G6Ojo+jt7V30P+q5Tld+/fXX8u98s2sPHjzAxo0b1dXz9vrrr+Pq1asYGhpCMBiUQaTD4UBXV5c8fXn79u28py43btyI48ePy3yxWAxCiHnNvhkzeMlkEr29vdi7d6+aJa8NGzaoq/Dw4UM4HA519bws5RiIVgsGX0S0pu3atUsGW2pA5PF48Ic//AHIzZxcvHjRkg4Ap0+flqf6PvjgAwQCAUu6ce1SNpvFr371K2zfvh3InSYcGRmR10ml02n09vZaTg+q3G533hkzQygUwuDgILq7u/H666/L9bW1tejo6JCvjQvOVQcPHkRXV5c8nmQyCU3T5v0bXcePH5fXvBnB2FxKSkrg8/lk/bLZLM6dO4empiY167ws9Rg8Hg8ePnyoriayFYMvIlrTbt68ifr6evj9fpSVlSEYDMpZktbWVrzzzjvQNA0nTpxAVVWVujk8Hg/KysqgaRrS6TQ++eQTNQucTieKi4tRVVUlfybC7Xbj448/RnV1NTRNQ1VVFU6cODHrDI1xas9896AqFAphZGQElZWVct2xY8eA3N18mqbhypUr6OrqMm3133bs2IE9e/Zg8+bN0DQN1dXV6Ovrm/dp2MrKSgwMDODw4cNq0qy6urpw5coVaJqGzZs3w+PxLPrnNJZ6DCdOnMCBAwfknY9EK4G/80W0wth/CqfQbanN8ptQiUQCW7duLdi+iFZSofsOzY4zX0REREQ24swX0Qpj/ykctiXR4rDv2IszX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2WvPBVzKZnPcvHxdKOp2e8zEkREREtD7ZGnzpui5/gVnTNHi9XvloDuRudZ3pV50Xq6KiAl999ZW6Oq9C7b+5uRmXLl1SVy+YruuW9lkukUgEuq6rq5FIJKBpGqLRqJok0wrRXsjVYb4Bq7HvfJLJJEKhkPyM+f1+9Pf3y/REIpH3eGYSjUYLdoxERESwO/gCgHA4DCEEhBDo7u7G+++/v6B/hgs1OTmZ99epC62/vx8tLS1A7h/2Yh+dsRrV1dVZZg+z2Sx++MMfLvrBuPk0Njbim2++UVcvWHV1NZxOJzKZDIQQOHToEF599VUZ2A0PD6O7u1vdbEbd3d0YHh5WVxMRES2a7cGXWXl5OUpLS/F//+//lev+8Ic/wO/3y5mxdDqNbDYLLfdcNUMymYTX67X8bWxjDubMszPZbBZ1dXVyViQUCs16SrK/v3/Gco196roOr9eL1tZW7N27F8gzYxWJROB0OmU55pmYaDQKr9crl/kGorNtp+s6Wlpa5AyQ0+m07DOZTMo21nUdY2NjMi2f2tpa/PjHP5avz549i6qqKpSWllryqe1lPFAYuffBeNiv+b010gBg69atcgYum80iFArB6XTC6XTO+V4ZUqkUdu7cKZ/zVlNTg3A4DOTeh8bGRgwMDFg+FzO1pa7rGBgYQGNjo6wj5jjOaDQq32u/329JI1oKXs5AtIaIAgAg5lNUIBAQ4XBYvo7H48LhcIienh4hcuX4fD6RSqWEEEIEg0HR3Nws/zZv29zcLF8HAgHR19cnhBAilUoJALIMACIej8ttgsGgpYxAICBfm/OmUinhcDjE+Pi45bWR7vF45N+ZTMayT/Nx9vT0CI/HI9P6+vqEw+GQZQKQ+xgfH7e0o9pehvlsZ65rOBwWPp9Ppns8HlluKpUSPp/P0g6GeDwuAIhMJiOPd3x8XDgcDpHJZEQgELC0l1onI5/I894GAgH53hrpRllCCFFbW2t5r8zvv1GvfJqbm4XD4RDNzc2yLmbhcNhyrPnqrbal+T3Il189TuNv472fC+bZf2hu+dpSfQ+XSv0M2UUdA2cyV/3i8bgcc59kcx1HOByW443dCv2Zs0O+vkPLx/aZL2MWQdM0/PCHP0RTUxNCoZBMP3XqFNxuNwBgy5YtuHPnDgDg4MGD6OzslPl6e3vxxhtvAAA2btyIc+fOIZFIwO12Ix6Po6ioSOY1nDlzBkeOHJGvjx07hoGBgbyzE0NDQygtLUVJSQkAwO12o7a2FqdPn1azzurq1as4fPiwPKYdO3ZgcnISAFBUVIR4PC73sWHDBiB3XdJs5rNdU1OTPN368ssvY3R0VOZJpVLytKjb7caePXvkdvm4XC60trbihz/8IRobG9HW1iZnlgxDQ0MIBAKyTiUlJfB4PJbr7czv7fbt2+V7m09NTQ1++ctfytdOpxM3btyw5MnnF7/4BT7++GNMTU2hoqICTqdz1uvm5tOWZnMdp8PhwNmzZ5FMJlFZWbmgU5wvvPAClyUua9lslzMYs/r5xjLVQk+9r1ZzHUehLmUgWhZqNLYY842Y5/o2oM5+qN/gPB6PGB8fF+Pj45b1mUxGzu4Ysx4Gc5lq+eo689/qvtV17e3tAoAIBALC4/FYvoGZj3O2Y85kMqK2tlbOPIXDYUsdZtp2oduZZ4ryzRrlO1aRJ28wGLTkC5hmvsLhsHA4HCIQCMjF4XDIeqhtr+5TTe/r65PHV1tbK8sUeeo1m3hudrW9vV2IPPtdaFvOdZypVErU1tYKj8cz7XMxE+T6D5fCLWaB3CxrIBAQAITH45Ez5cL0GTC2DQaDcvZS5GY3fT6fQK6/G/1AnfE28qqznT6fz/I5CAaDljzxeFy+NsY2AJazAiLPZ7G5uVl4PB457vX09Mix0Dhmh8MhAMjtjM+3sZj7nMi1hXn/5rFU7TtC6bdztTMA0d7eLjwej2xL8+y0euz59t3c3CyPZ7bjMKcZdZ7rfTYY40tPT8+0MwhGexrvv8GY5QYgxxOjzfONV+p7aS5bbbe+vj5ZtvE/cDkY7UL2+P/UYGw1CwaDuHDhAgDghz/8oVz/1VdfoaGhAQ0NDUin06iqqsIrr7wy7UJ79QJx4xoiY7bDLN/M2YMHD7Bx40YAwDvvvINUKiVncmZi5M/n0qVLSKfTuH37tlzX2NhoyZPPYrdbqtmuRysqKkJVVdWseRbiwIEDuHbtmnwPI5HInDNfyWQSjY2NiMVicl15eTmamppw5coV1NTUWPJjEW0523Fms1k8evQIbW1tQG72bOvWrZaZ3dmMj4+rq2iBZpr9OnPmDG7evIlYLIZoNIoDBw7g3r17cLlc+PDDDzE5OYn//v8DtLS0YP/+/fJzVF1djcOHD+P27dtIp9MIBoNwuVxwuVwIBoO4dOmSnJG6cOECDh8+bNn3oUOHcPXqVfk56O3thcfjQTqdhtvtxmeffYZgMCj3dfz4ccRiMWSzWZSVleFv/uZvpo1l0WgUd+7cwcTEBJCr8+effy73MTAwgN27d2NychLJZBIvvPAC3nzzTVnPGzduWPqJ4ezZs3jppZfk/nVdx/e///15f4Zna2cA6Orqwq1bt+ByuVBXV2fpr4cOHcKhQ4fkvvfv349IJCLrbByT8T5hluMQQkDTNMTjcdl2c73Pqs8//1zWPRqNorOzU77u6OiQ26bTaezbt0/uazF3VHd2dmJ0dBRutxv9/f04cOAAJicnkU6n8eqrr2J8fBwlJSVIJpOoqKiwtCk9odRobDHmGzGr0b4Kc8yOGNdd+Xw+y7cO87eTjOn6JKGUqV7zpZbvcDgs1445lGu+zOWq37x8Pl/e2RL1mi/zNUXq/o0yjXLM17yZzbWd2s7qNy+PxyNnguZzzddMAso1X+ZvZcb7YLTnXO+t+m3PnN+YeTDyG22Y71urw+EQtbW1Mi2em1Uwjrenp8dy/ZtaD7Uta2trLe/BbMepXv9lfq9nY3yGaOnytaXaH4RyzaZ5/BCmazjHx8fz9gHzZ8aYlTCY+7rB+FyI3OcxGAyK2tpa+Zk0xo58n5dm5dpW87hi/tw2NzeL2tpaIfJ8poXSn/KlG9rb24XP5xN9fX0ik8mI8fFxeTz5tptt3BFKO6tjgHH9pJihr5ivj82373zrzNT9zfY+m+V7z9Xr7YxtxQz1MLdFvvLM6WrZZu3t7dPKNv+vKaR8fYeWj+3XfC2F2+2Gx+OB3++3RP03b95EfX09/H4/ysrKEAwGp31TRO4aL+NONE3TMDY2hk8++USmNzU14dVXX0UkEoHb7cbHH3+M6upqaJqGqqoqnDhxAuXl5Uin07h48aL8OQOR+0mDEydOWPYHAKFQCIcPH4bP54OmaaiurkZfXx8A4M033wRyd/t5vV48//zzlm0PHjyIM2fOTPsNrrm2m8vly5fxb//2b9A0DXV1dXNe8zUfbrcbra2tsr02b96Mw4cPY8eOHWrWvE6cOIEDBw7Iuwp7enqwa9cuaLm7JKuqqmTekpISBAIBFBcXT7s26+bNm5icnERxcbG8rvDw4cNy1quyshIulwuapiESiczZljU1Nejt7YWWuztytuMsKSlBW1sbysrKoOs6qqur0dPTYymPVgdv7k5pAJiamrKkGWPLo0ePLOvzMT7fyWRS3gGtzoaXlJTA6XQikUjgs88+Q0VFBXbu3ImbN28im80ilUqhvLxc7k/Xdbn09vbmnfGtrKzExMQEvF4v/H4/7ty5g5///OdqtgWrqanBW2+9hdbWVhQXF+PkyZN5zwLMl7mdVeZ2ytfWTz/99LT3ZinUshbyPt+/fx+dnZ3yfdm/fz8wy7WhC3H//n11lfTgwQOMjIxYPhOpVIo/f7MWqNHYYtgVMRuzDOo3FbuN567rMM+8tLe3W2bViObLrv6zHuRry7lmZGabEck3a6HOdDQ3N8tlpmv8jHRf7o5fYx89PT1yxso8Q5aP+Tja29vldiq1fmIBM1/j4+NyXMtkMpZZmXzbmcudq53NecUTOPNlzFSq8tWjkDNfdv1fydd3aPk8MTNfkUgExcXFCAaD8k6zlVJSUoLDhw/LGQ6v14ubN2/io48+UrMS0SrQ2dkpfyMrGo1icnIS3/ve94Dc79iZ72I+e/asvKO1vLwcHo8HHR0dQO63ti5evCjzIjcTfebMGQwODqKystKSZnjllVfQ29uLqakpuN1uuFwuBAIBvPvuu9i5cydgunPWfL1QKBSSP95s9sYbbyAajcpZfKfTibq6OjVbXs8+++yMv5l38uRJnD17FjDNDBmeffZZTExMIJvNIpvN5r2LeLZ2BoDTp0/LfX/wwQcIBAJA7th9Pp9s52w2i3PnzqGpqUluq5rtOADA4/Hg4cOH8vVs7/NcDh48iK6uLrm/ZDIJTdOQzWbxxhtvWO6aTyQSGBkZkdtu2rRJboNcu5jTX3/9dUu7GWUjN8M5Ojoqt81ms/AqvxVJTyg1GlsMRsxEi8f+Uzj52jJgukMRee4Yy8xxF5wx043cXW75Zjp8Pt+MM1EGh3IHn3HHtLovo57I3TlnpJtnS5qbmy0zMcZZgXg8nrd+MM0CZUx3NKozLsZslyd3t67aFsZ2jtzdleZy52pnAKI5d4em0ZYzHbvaVvmOabbjELnr4hy5OwiN/LO9z4Z8M1UiVwejPOM6T4N5X7W1taK2ttZSp7DpGuHm3B2havpMZZvvdnSY7qwuNKN+ZA9N/HejL4kRpRegKKJ1h/2ncFaiLY27Ei9fvjyvWZRCCIVCqKiokNcyrkQdVLquY/v27TP+Fpmm3H1Iq8tK9J317Ik57UhEtNqs1OUQ77zzDm7evAlv7hFnZWVlOHHihK11IKLF48wX0Qpj/ykctiXR4rDv2IszX0REREQ2YvBFREREZCMGX0REREQ2YvBFRGtaOp2G1+uVTymYizlfJBKZ9oQJIqKlYvBFRGva0NAQvF4vhBD8mQMiWhUYfBHRmhWJRPCjH/0IAwMDlhmtlpYWOJ1O+WxE4xfE52I8v1HLPQvU/Gv0RETzxeCLiNashoYGhMNhBAIBOfMVjUbR29uLe/fuYWJiAocOHUJjY6O6aV6NjY1obW2FEAKDg4PYt2+ffCwMEdF8MfgionWltLQUly9fls8uLCoqwsDAgJotr40bN+LcuXNIJBJwu92Ix+MoKipSsxERzYrBFxGtK48ePcLJkyfh9/sRCoXw+eefq1lm9NFHH2HLli2or6+H0+nEZ599Nu0B1EREc2HwRUTrysmTJ7Flyxbcvn0b0WgUP/jBD9QsM/rqq6/Q0NCA27dvY3R0FL29vfO6g5KIyIzBFxGtK/fv35d/Z7NZnD592pLucDjw8OFDIHdKMpvNyrRdu3bJYIunG4losRh8EdG6Eg6H0dnZCU3TsH//flRUVFjSm5qa8OqrryISiaCyshJTU1PyuXc3b95EfX09/H4/ysrKEAwG+fMVRLRgfLA20Qpj/ykctiXR4rDv2IszX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2YvBFREREZCMGX0REREQ2Kkjw9cwzzwAAvv32WzWJiGZh9BmjD9HScCwiWjiOQ/YrSPC1adMmAMDQ0JCaRESzMPqM0YdoaTgWES0cxyH7FST4evnllwEAExMTahIRzcLoM0YfoqXhWES0cByH7FeQ4Gvnzp0AgAsXLuDx48dqMhHl8fjxY1y4cAEw9SFaGo5FRAvDcWhlFCT40nUd27Ztw927d3Hs2DE1mYjyqK+vx927d7Ft2zbouq4m0yJwLCJaGI5DK0MTQgh15WJ88cUX2LJlCwDg2rVreO2119QsRJTz6aefYteuXQCAsbExvPjii2oWWiSORUTzw3Fo5RRk5gsAXnzxRYTDYQBAdXU1Pv30UzULEeUGvOrqagBAOBzmgFdgHIuI5sZxaGUVbObLEAgEMDg4CAD4yU9+glOnTuGpp55SsxGtO48fP8axY8fQ2toKAKiqqsLAwICajQqEYxHRdByHVoeCB18AEIlE0NjYCAB47rnnsHfvXni9XlRWVuK73/2ump1ozfr2228xNDSEiYkJXLhwAXfv3gVy3zQbGhrU7FRgHIuIOA6tSmKZjI2NiW3btgkAXLhwyS3btm0TY2NjanehZcSxiAsX68JxaOUty8yXWSwWw/Xr1zE8PIxvvvkGf/rTn9QsRGvWM888g02bNuHll1/Gzp07eTfRCuJYROsVx6HVZ9mDLyIiIiL6i4Ld7UhEREREc2PwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENmLwRURERGQjBl9ERERENvr/Ax2ztb4tcQ6FAAAAAElFTkSuQmCC\"\u003e\u003c/p\u003e\n\u003cp\u003eOutcomes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Activities Of Balance Confidence (ABC) was selected from the neurological core set of clinical measures\u003csup\u003e27\u003c/sup\u003e to measure confidence and the PDQ-39 \u003csup\u003e19\u003c/sup\u003e mobility scale was also selected to assess overall quality of life. A descriptive qualitative study was also completed to understand the experience of participating in the selected intervention from the perspective of the participant.\u003c/p\u003e\n\u003cp\u003eData Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eABC and PDQ-3 mobility scores produced were compared to MDCs (standard measures of error, SEM, were also used if an MDC wasn\u0026rsquo;t available) and significance was determined if minimal scores were reached or above the threshold for error. Thematic analysis was completed following individual interviews to determine common threads within the conversations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable 3 presents data for all outcome measures including minimal and maximal performances, pre and post intervention differences as well as compared results to published MDCs within the PD population. The datasets used and analyzed during this current study are available from the corresponding author on a reasonable request.\u003c/p\u003e\n\u003cp id=\"_Toc89372482\"\u003eTable \u0026nbsp;3 Pre and Post Intervention Results for PDQ39 mobility and ABC Across Participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePDQ39(mobility)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003ePre-Intervention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e47.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e32.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e52.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003ePost Intervention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e33.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eChange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eABC (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003ePre-Intervention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e62.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e66.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e98.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e62.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e83.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003ePost Intervention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e76.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e71.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e99.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e83.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e64.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e(+)13.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e(+)5.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e(+)0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e(+)20.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e(+)18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eQOL:\u0026nbsp;\u003c/em\u003eThe PDQ-39 was administered to assess quality of life after participation in an moderate intensity driven walking program. This study chose to only focus on the mobility subscale secondary to selected outcomes of interest looking at functional mobility as the primary goal. Analysis of the PDQ-39 mobility subscale, a scale that assesses percentage of perceived disability from 0% (no impairments) to 100% full impairment, revealed that 4 participants that had detected mobility QOL impairments at baseline (range 22.5% - 55.21%) reached minimal detectable thresholds after participation in an moderate intensity driven intervention program. An average improvement of 16.75% was noted for participants 1,2,4 and 5 on mobility subscale questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Interviews:\u0026nbsp;\u003c/em\u003eA descriptive qualitative study, in addition to the PDQ-39 mobility assessment was completed, to further investigate the nonmotor impacts of PD. The interviews aimed to understand the experience of participating in an intensity-based exercise program from the perspective of the individual. Open ended interview questions were asked in the research laboratory where the study took place and remarks were transcribed verbatim by the primary investigator. Specific questions focused on how individuals felt after participating in an intensity-based intervention and if they perceived any notable changes during their daily routines.\u003c/p\u003e\n\u003cp\u003eThematic analysis was conducted following the interviews to search and identify common threads that were used to describe the overall experience of participating in a moderate intensity walking program across all 5 participants \u003csup\u003e20\u003c/sup\u003e. Analysis revealed four emerging themes common across the 5 participants which included overcoming fear, accountability, improvement, and confidence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTheme 1 - Overcoming fear\u003c/em\u003e: Our participants were generally at first hesitant about trying a new, unfamiliar exercise intervention. Feelings of fear and uncertainty were expressed with trying something that was not a part of their daily routines which made them also feel nervous at the start of the study. Doubt of individual abilities was also a common occurrence when asked about the experience of participating in a walking program that was going to be delivered on a treadmill. None of the 5 participants had previously used a treadmill for exercise. The fear of not knowing what to expect and of the possibility of failure was a common theme throughout the interviews. However, the sense of accomplishment after completing the intervention was reflected in the strength and surprise of being able to achieve exercise levels that were at first thought to be impossible. The participants expressed:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;Scared that it was going to be challenging but it wasn\u0026rsquo;t too bad\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;It was hard at first then got easier\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I wasn\u0026rsquo;t able to walk as far from the start but then I surprised myself\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I didn\u0026rsquo;t think I could but then I was able to finish\u0026rdquo;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eTheme 2 \u0026ndash; Accountability:\u003c/em\u003e Motivation to participate in our selected intervention came from not only wanting to improve their walking but also was fueled by adhering to a responsibility to themselves, the primary investigator, other individuals with PD and their families. The ability to be a part of a research project gave a purpose to the participants and held them responsible to fulfilling an obligation. Participant 3 felt that it was his duty to participate in research opportunities so that other individuals with PD could benefit in the future. Participant 2 said that her husband has been pushing her to exercise more and used this as motivation to seek out opportunities that were available in the community. \u0026nbsp;Overall, the individuals shared:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;I didn\u0026rsquo;t want to let you down\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I want to keep it up, it has been good for me\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;If I can help someone else with PD then it was worth it\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I want to work out because I have somewhere to go\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;My husband has really been on my case about exercising more\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo; PD shut my world down. This gave me a purpose\u0026rdquo;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eTheme 3 \u0026ndash; Improvement:\u003c/em\u003e Overall, the experience of this intervention was well received which was made apparent in the activities that were now possible or easier since starting the intervention. Functional mobility gains were noted in routine activities that were meaningful to the participants. When asked about changes and activities they could now do the participants stated:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;I am able to walk my dog more\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I can get around the block faster than I did\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;My balance feels better\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Getting up from a chair is easier\u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I lost weight\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I can walk across a street faster in a big city\u0026rdquo;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eTheme 4 \u0026ndash; Confidence:\u0026nbsp;\u003c/em\u003eFinally, there was a notable increase in daily life confidence that was not only reflected in personal experiences but from the perspective of surrounding family members as well. When asked what was different now in their daily lives after participating in this study, the participated noted:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;I can walk to the parking lot without getting out of breath\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;My family noticed I wasn\u0026rsquo;t so tired\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I can now cross the street faster with my son\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;My husband was surprised that I mowed the lawn for the first time in 4 years\u0026rdquo;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I can get the mail without getting tired and help around the house\u0026rdquo; \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eA comprehensive understanding of personal benefits that were achieved at the end of our study was reflected not only in the qualitative remarks but in the quantitative improvements on both PDQ-39 and ABC scores. All 5 participants demonstrated improved scores on both the PDQ and ABC, with at least 3 out of 5 participants reaching established MDC. Overall, participants in this study overcame fear and doubt about participating in a new intensity driven exercise program by utilizing motivation found within themselves and others around them to achieve salient improvements in their daily lives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAddressing the nonmotor symptoms of PD is needed by targeting known barriers to exercise that currently exist. Known barriers to exercise such as low outcome expectation and poor motivation have been found to limit participation in exercise \u003csup\u003e21\u003c/sup\u003e. Low outcome expectations and poor motivation are commonly expressed secondary to the progressive nature of PD when individuals are not expecting to see benefits \u003csup\u003e22\u003c/sup\u003e. Fear of falling, another common reported barrier, has been associated with restricted activity levels \u003csup\u003e23-25\u003c/sup\u003e.Regardless of the known benefits to exercise, if barriers are not addressed, then individuals will not seek out opportunities to manage life with PD.\u003c/p\u003e\n\u003cp\u003ePersistence to overcome common barriers of exercise are also influenced by ones self-efficacy \u003csup\u003e26\u003c/sup\u003e. Self-efficacy, rather than disability, appear to be strongly associated with whether ambulatory individuals with PD exercise regularly \u003csup\u003e27\u003c/sup\u003e. Our study focused on providing an environment that would address the sources of self-efficacy.\u003c/p\u003e\n\u003cp\u003eIndividuals were given an opportunity to work one-on-one with a PT that had experience in working with individuals with neurological disorders. The American Academy of Neurology advocates not only for individuals with PD to participate in exercise to manage symptoms of PD, but also recommended regular physical therapist assessments to be completed at least twice a year \u003csup\u003e28\u003c/sup\u003e. Our study provided an opportunity for individualized sessions from a neurological specialist PT that had knowledge in gait, mobility, and PD specific interventions.\u003c/p\u003e\n\u003cp\u003eUtilizing an intervention that addressed not only the motor symptoms, but the multifactorial components of PD as well, provided the optimal solution to addressing this variable disorder. By addressing individual self-efficacy through safety mechanisms, mastery of experiences and positive verbal persuasion, we were able to motivate exercise participation. Providing an environment that was safe was implemented to attempt to reduce exercise induced anxiety. Utilizing a body weight support (BWS) harness provided a mechanism in which individuals with PD could exercise without the fear of falling or losing their balance, both common subsequent complications of this disorder \u003csup\u003e29\u003c/sup\u003e. BWS has been shown to reduce dropout rates, improve mobility and decrease overall anxiety with exercise practice in other neurologic populations \u003csup\u003e30\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In addition to providing a safe environment, opportunities to improve both confidence and motivation were included that were delivered by the PT to boost participant self-efficacy. Self-efficacy, rather than disability, appear to be strongly associated with whether ambulatory individuals with PD exercise regularly and those that demonstrate poor motivation tend to exercise less\u0026nbsp;\u003csup\u003e27\u003c/sup\u003e. The selection of a single subject design boosted motivation for individuals in which they were to complete against themselves. Session updates throughout the study provided individuals with up-to-date progress on outcome measures that they could see being graphed. Verbal motivation provided by the PT during sessions gave structured goals that were obtainable, and reminders of how hard individuals were working. This attention provided to improve participant self-efficacy drove motivation to continue with the exercise program which was evident in the zero attrition rates of this study. Both motor and nonmotor factors needs to be addressed to see substantial improvements in functional mobility for individuals with PD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, the impact of addressing this multifactorial disorder was reflected in the gains noted in quality of life. This was another focus of our study because QOL has been reported to be highly correlated with motor impairments involving difficultly with walking, speaking, and maintaining balance \u003csup\u003e31\u003c/sup\u003e. In addition, nonmotor symptoms of cognition, stigma, body discomfort and emotional well-being have also been identified as key contributors to QOL \u003csup\u003e31\u003c/sup\u003e. This again reinforces the importance of recognizing both the motor and nonmotor symptoms of PD and providing options to target all aspects of this progressive, neurodegenerative disorder that currently has no cure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter participation in a intensity driven exercise intervention our study found that 4 out of the 5 of the participants reported substantial changes in their functional mobility QOL Improvements across all 5 participants were noted on item number 4, \u0026ldquo;Have you had problems walking a mile\u0026rdquo; and item number 7 \u0026ldquo;Have you had difficulty getting around in public\u0026rdquo;. Both questions identify the importance of endurance to participate in activities outside the home. It seems to be that the gains made after participating in the study not only improved confidence in distance but were also able to be generalized to daily functional mobility activities that are required to be independent in the community. The increased confidence in functional mobility was reflected in significant gains made on the PDQ-39 and provides an understanding of the impact of this program on overall perceived quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitive reflections provided by our participants strengthened our confidence that our intervention had a meaningful impact on daily lives. Addressing self-efficacy throughout our intervention allowed individuals to overcome fears about trying new evidence-based exercise interventions to combat this multifactorial disability. Addressing possible sources for anxiety by providing a supportive environment that included individualized assistance and a body weight support to reduce the fear of falling allowed participants to focus on improving motor impairments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMotivation to improve was provided not only from the primary investigator but surrounding support systems that were already in place for the participants. Neurological disorders, especially PD being progressive, not only impacts the individual but the surrounding family as well. Even though there were significant changes noted on the PDQ-39 mobility scale scores to draw attention to improved quality of life, the biggest gains were heard in the verbal improvements in daily activities that included family involvement. Though participants all mentioned positive changes in their day, participant 2 demonstrated one of the most substantial differences that was reflected from a family members perspective. Participant 2 mentioned: \u0026ldquo;I can\u0026rsquo;t believe it. I was able to keep up with my son for the first time while crossing the street to his soccer game and walking across the field to where he needed to meet his team. For the first time, in a long time, I don\u0026rsquo;t think he was embarrassed to be seen with me. I just felt normal\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eQualitative remarks from participant 2 remind us of the daily struggles that individuals with PD face. Living with PD is a life altering disorder that can result in social embarrassment that may be from motor symptoms, non-motor symptoms, loss of autonomy, or from the need for help \u003csup\u003e32\u003c/sup\u003e. Regardless of the source, all these factors impact not only QOL but activities that were once able to be completed without any struggle that allowed for family. To fully address the multifactorial impact of PD, interventions need to target all aspects of this disorder to see optimal results and return some control back into lives that have been turned upside down from this progressive neurological disorder.\u003c/p\u003e\n\u003ch2\u003eStudy Limitations\u003c/h2\u003e\n\u003cp\u003eWhen interpreting the results of this study external validity is limited due to the small sample size. Direct intra-participant replication was achieved which will allow for future larger studies to replicate the results. Inter-observer agreement and procedural reliability was not collected concurrently throughout conditions which could have strengthened the validity of study finds.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eProviding the most beneficial interventions for individuals with PD is challenging due to the variety of symptoms that encompass this disorder. Both motor and nonmotor impairments associated with PD directly impacts one’s functional mobility potential. Despite the progressive nature of PD, this relationship between personal factors and exercise offers optimism for individuals with PD and clinicians treating this disorder. This relationship suggests that improvements are potentially modifiable. If we can exhibit control over one’s exercise behavior then we can improve symptoms, regardless of the defined disability. When designing intervention programs for individuals with PD, one should include strategies to increase one’s exercise self-efficacy as well as functional mobility for optimal achievable outcomes. These findings support the use of interventions in a structured environment that provides opportunities to improve self-efficacy. Future research is needed to replicate these results to a larger population and to seek out other opportunities to provide real world opportunities for this type of practice.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding : No Funding\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMartinez-Martin P, Schapira AHV, Stocchi F, et al. 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Quality improvement in neurology: AAN Parkinson disease quality measures: Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology. \u003cem\u003eNeurology\u003c/em\u003e. 2010;75(22):2021-2027. doi:10.1212/WNL.0b013e3181ff96dd\u003c/li\u003e\n \u003cli\u003eBloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson\u0026apos;s disease: a review of two interconnected, episodic phenomena. \u003cem\u003eMovement disorders\u003c/em\u003e. 2004;19(8):871-884. doi:10.1002/mds.20115\u003c/li\u003e\n \u003cli\u003eSharan D, Rajkumar JS, Balakrishnan R, et al. Effectiveness of a low-cost body weight support training device in the rehabilitation of cerebral palsy. \u003cem\u003eJournal of rehabilitation and assistive technologies engineering\u003c/em\u003e. 2016;3:2055668316676047-2055668316676047. doi:10.1177/2055668316676047\u003c/li\u003e\n \u003cli\u003eTu X-J, Hwang W-J, Ma H-I, Chang L-H, Hsu S-P. Determinants of generic and specific health-related quality of life in patients with Parkinson\u0026apos;s disease. \u003cem\u003ePloS one\u003c/em\u003e. 2017;12(6):e0178896-e0178896. doi:10.1371/journal.pone.0178896\u003c/li\u003e\n \u003cli\u003eAngulo J, Fleury V, P\u0026eacute;ron JA, Penzenstadler L, Zullino D, Krack P. Shame in Parkinson\u0026apos;S Disease: A Review. \u003cem\u003eJournal of Parkinson\u0026apos;s disease\u003c/em\u003e. 2019;9(3):489-499. doi:10.3233/JPD-181462\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8175308/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8175308/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nParkinson’s Disease (PD) exerts both motor and nonmotor symptoms that collectively reduce quality of life. While motor impairments are often the focus of clinical management, nonmotor symptoms such as depression, anxiety, cognitive decline, and low self-efficacy significantly contribute to decreased motivation, sedentary behavior, and diminished well-being. Addressing these multifactorial symptoms is essential to improving meaningful health outcomes and overall life satisfaction for individuals with Parkinson’s Disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003cbr\u003e\nThis single subject design withdrawal design mixed-methods study aims to examine how a supportive walking intervention can enhance confidence, promote engagement in physical activity, and improve overall functional mobility for individuals with Parkinson’s Disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nFive participants with PD participated in an intensity-based walking intervention program provided in an environment with opportunities to improve self-efficacy and quality of life. PDQ-39 and Activities of balance confidence scores were obtained pre and post intervention study to assess both quality of life and mobility confidence. In addition, phenomenology qualitative semi structured interviews were completed and thematic analysis was conducted to understand the impact of the intervention on nonmotor symptoms to PD after participating in the intervention program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003cbr\u003e\n All 5 participants demonstrated improved scores on both the PDQ and ABC, with at least 3 out of 5 participants reaching published and established minimal detectable changes within this population. Thematic analysis revealed four emerging themes common across the 5 participants which included overcoming fear, accountability, improvement, and confidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\n Our findings support the use of interventions in a structured environment that provides opportunities to improve quality of life, confidence and self-efficacy. Choosing an environment that enhancing self-efficacy may represent a critical strategy for improving both motor and nonmotor outcomes in PD. These findings may also help inform future rehabilitation approaches aimed at promoting independence and improving overall quality of life in this population\u003c/p\u003e","manuscriptTitle":"Self-Efficacy Ingredients for Success: A Mixed-Methods Study Addressing Nonmotor Symptoms and Quality of Life in Parkinson’s Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-13 12:44:17","doi":"10.21203/rs.3.rs-8175308/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-06T16:37:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-29T06:58:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-05T13:19:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-03T16:05:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-03T15:58:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a7c989c-97fb-41f2-9c94-826c44d42007","owner":[],"postedDate":"April 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":65801619,"name":"Health sciences/Diseases"},{"id":65801620,"name":"Health sciences/Health care"},{"id":65801621,"name":"Health sciences/Neurology"},{"id":65801622,"name":"Biological sciences/Neuroscience"},{"id":65801623,"name":"Biological sciences/Psychology"},{"id":65801624,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-04-13T12:44:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-13 12:44:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8175308","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8175308","identity":"rs-8175308","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}