Experiences from the implementation of physical therapy via telehealth for individuals with Parkinson disease during the COVID-19 pandemic

Abstract Purpose To (1) determine the characteristics and participation rate of adults with Parkinson disease (PD) in physical therapy (PT) delivered via telehealth, (2) identify the outcome measures and interventions implemented, (3) determine the safety of and (4) patient and therapist satisfaction with PT via telehealth in a clinic specializing in the care of people with PD during the coronavirus pandemic. Materials & Methods A retrospective analysis of PT services via telehealth was conducted. Participating patients completed a satisfaction survey. Physical therapists (PTs) who delivered this care were interviewed. Three coders conducted thematic analysis of interviews. Descriptive statistics described the participation rate, demographics, outcome measures, interventions, and safety. Results There was a 71.4% participation rate. Participants (n = 55) were white (96%), non-Hispanic (100%), older adult (mean = 69.5 years (8.3)) males (65.5%). Non-participants (n = 22) had similar demographics. Therapists selected patient-reported measures more often than performance-based measures. Therapeutic exercise was the most common intervention. All patients (80% response rate) reported satisfaction with their experience. PTs reported the home enhanced specificity of training but impeded evaluation. Therapists endorsed a hybrid model for future practice. Conclusions Patients reported satisfaction with PT via telehealth during the pandemic. A hybrid model may support optimal delivery of PT. IMPLICATIONS FOR REHABILITATION Physical therapy via telehealth for patients with Parkinson disease was acceptable to patients and physical therapists in our study. Physical therapy via telehealth was safe for people with Parkinson disease in our study, although availability and benefits may not be reaching all populations equitably. Both physical therapists and patients endorse a hybrid model of care (a combination of in-person and remote assessment and treatment) to profit from the strengths of in-person and virtual formats while minimizing barriers to access.


Introduction
As the coronavirus pandemic and the subsequent restrictions impacted the United States, many physical therapy (PT) clinics pivoted to providing telehealth services.For individuals with chronic progressive health conditions, such as Parkinson disease (PD), telehealth provided a mechanism to continue delivering essential physical therapy services while simultaneously reducing risk of exposure to the virus.Here we define telehealth using Medicare's definition, "The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home."Other studies that assessed telehealth services during usual physical therapy practice largely focused on patients with musculoskeletal conditions [1][2][3][4].In persons with PD, most remote interventions examined have been limited to exercise instruction and/or monitoring of adherence [5][6][7][8][9].The delivery of specific types of exercise, such as tango dancing [5] and Baduanjin Qigong [9], has been studied via telehealth for individuals with PD.While useful, such studies fail to address the full breadth of physical therapist practice which is individualized to each patient's presentation and is not restricted to one type of exercise or protocol.Studies that have examined telehealth to deliver physical therapy for people with PD have also incorporated interventions using virtual reality, which is not widely available in usual practice [10].Since the pandemic, several studies have assessed the feasibility of PT via telehealth for people with PD [11][12][13].Although these studies have indicated that telerehabilitation is safe and feasible they were limited by small sample sizes (n = 15-23), extensive exclusion criteria that limit clinical applicability (e.g., excluded individuals using an assistive device or those with mild cognitive impairment), and included a caregiver for all telehealth sessions.Our study analyzes clinical practice that included a larger, more inclusive sample (e.g., included individuals using an assistive device, did not exclude based on cognitive status or the availability of a caregiver to be present during sessions) and included the delivery of personalized PT interventions that were not limited to a standard set of interventions dictated by a study protocol.Our study seeks to address the limitations of the existent literature by examining the implementation of physical therapy practice that is delivered via telehealth during the COVID-19 pandemic, providing clinical data regarding participation rates, barriers to access, clinical practice trends, safety, and patient and clinician perspectives, in a larger and broader population of persons with PD.
Satisfaction with PT services delivered via telehealth is mixed in people with PD.In a study of telecoaching for exercise for people with PD, participants indicated that benefits of telecoaching included convenience, accountability, enhanced motivation, and increased confidence with exercise and technology as positive experiences [8].In a feasibility trial of telerehabilitation for individuals with PD, >90% of participants indicated that they were "extremely satisfied" or "very satisfied" with the telerehabilitation program and the remote visit modality [13].Participants in a physical activity coaching program via telehealth that was delivered by physical therapists rated their satisfaction with the telehealth program 4.85/5 [14].However, in a recent large survey (n = 944) of individuals with PD, based upon their experiences over a 12 month period (2020-2021), 56.9% indicated that they were less satisfied with PT via telehealth (phone or video) compared with in-person PT [15].Furthermore, satisfaction among physical therapists with delivering PT services via telehealth for people with PD is largely unknown.Neurologists have reported satisfaction with virtual assessments of people with PD [16,17], however, physical therapy practice typically encompasses assessments and interventions focused on mobility which may influence satisfaction when delivered remotely.
To better understand the feasibility and generalizability of providing PT services via telehealth, it is also critical to identify the characteristics of those who do and do not participate.Most of the evidence is derived from studies that have focused on care administered by medical doctors specializing in neurology [17][18][19][20][21].Of these studies, most participants were in their mid-sixties, white, college-educated with fairly equal representation of males and females and living with PD for approximately 6-8 years.In a study focused on physical activity management for people with PD via telehealth, similar demographics were seen in participants, with the majority of patients being White and many highly educated [22].In a study using virtual reality for telerehabilitation for people with PD, close to 15% of those screened did not participate due to technological problems, a lack of motivation to use technology, or a lack of an Internet connection [10].
The purpose of this study was to (1) determine the rate of participation of adults with PD in PT delivered via telehealth during usual physical therapy practice in the United States during the coronavirus pandemic and describe the characteristics of those who participated in/declined telehealth, (2) identify the outcome measures and treatment interventions that were implemented during PT delivered using telehealth, (3) determine the safety of PT delivered via telehealth for people with PD and (4) describe patient and therapist satisfaction with telehealth.

Study design
This is a retrospective analysis of a clinical dataset from the delivery of PT services via telehealth at the Center for Neurorehabilitation (CNR) at Boston University (BU) between March and June 2020 (during the initial stages of the coronavirus pandemic in the United States).The CNR is a physical therapy clinic specializing in the care of people with PD in an urban environment.In addition, we conducted semi-structured interviews, after 3.5 months of implementation of services via telehealth, to assess physical therapists' experiences using telehealth in the delivery of services.Boston University's IRB determined that this project did not meet the definition of research under 45 CFR 46.102(l).
Patients and therapists participated in the telehealth sessions from their home environment and met using a virtual meeting platform that had the encryption and safety necessary for a healthcare encounter.Therapists observed the patient's mobility in several environments in the home (e.g., kitchen, bedroom, hallway, thresholds, outdoors, etc.) to determine the best location to conduct each session.

Patients
All individuals with idiopathic PD who were evaluated, continued care, or completed an episode of care at the BU CNR via telehealth between the dates of 23 March 2020 to 30 June 2020 were included in this analysis.Individuals were excluded if they had a primary diagnosis other than PD.Patients (N = 55) were categorized into groups depending on their interaction with our center and telehealth.These groups consisted of: (1) new patients (patients evaluated via telehealth that were unknown to the CNR) (n = 15), (2) existing patients (patients who began their episode of care who had been evaluated and receiving in-person care at the CNR well before the pandemic) (n = 29), and (3) hybrid patients (patients who were evaluated just prior to the COVID-19 shutdown and continued their episode of care via telehealth) (n = 11).
All therapists at the center consented to participate in interviews.Three physical therapists, working for an average of 13 years (range: 9-18), and two physical therapists, who were residents in neurologic physical therapy, with approximately one year of practice, participated.None of the therapists had prior experience in telehealth.Two therapists were board certified in neurologic physical therapy while one was certified in geriatric physical therapy by the American Board of Physical Therapy Specialties.

Outcome measures
Medical records were reviewed to identify outcome measures used by the therapists via telehealth.Outcome measures were classified as either patient-reported outcome measures or performance-based outcome measures.Most patient-reported outcome measures were completed via electronic surveys.

Interventions provided
Medical records were reviewed to determine the types of treatment that were implemented by the physical therapists via telehealth and entered into categories.Treatment descriptions were categorized as follows: therapeutic exercise, gait and balance training, functional activity training, and patient education.Details of implementation were obtained during therapist interviews.

Safety
Medical records were reviewed, and therapists were queried if any injuries, falls, or unanticipated medical complications occurred during the course of treatment via telehealth.

Telehealth patient satisfaction survey
The Client Satisfaction Questionnaire (CSQ-8) [23] was modified to specifically assess satisfaction with PT via telehealth.The CSQ-8 was specifically designed to assess consumer satisfaction in health and human services and has high internal consistency (α = 0.93) to measure general satisfaction with services and concurrent validity as it is significantly correlated with therapist assessment of client satisfaction (r = 0.56, p = 0.001) [23].The CSQ has been effectively used to assess satisfaction of other digital health interventions [24][25][26].The survey consisted of 14 questions (10 multiple choice, 4 open-ended), that inquired about satisfaction regarding patient experiences with the technology and overall physical therapy experience (Supplementary Appendix).In July of 2020, the survey was distributed to all individuals that had participated in at least one session of physical therapy via telehealth.Patients anonymously completed the survey that was provided either electronically or in printed format and sent through the mail.A member of our research team placed a follow-up call to encourage survey completion or provide assistance.

Therapist perspectives
We conducted semi-structured interviews to evaluate therapist satisfaction.All semi-structured therapist interviews were conducted by the first author (CCS).Interviews were recorded via Zoom and transcribed verbatim by two research assistants.The interview included questions such as, "How satisfied are you with the implementation of PT services via telehealth?" and "Can you compare this with in-person PT services?"(Supplementary Appendix).Interviews lasted approximately 30-45 min.

Data analysis
Descriptive statistics were used to describe demographic characteristics of patients who engaged or did not engage in telehealth, the outcome measures and treatments administered by therapists via telehealth, and patient satisfaction.Content analysis [27] was conducted to capture therapist perspectives on telehealth.First, two researchers independently reviewed the recordings and the manuscripts of interviews to become familiar with the data and identify initial main ideas.The two coders then developed initial codes using these main ideas and applied them to the data.The focus on these initial codes was to capture barriers and supports to deliver telehealth and factors that influenced therapist satisfaction.Example codes included advantages and disadvantages of telehealth, technology, and communication/relationships.Next, they examined the coded data to further clarify the codes, combining, refining, and expanding codes, as necessary, resulting in 11 refined codes (e.g., usability of technology, therapists felt limited in assessment and treatment).They applied these refined codes to the data and further collapsed codes with similar content to develop themes.A third researcher worked with the two coders throughout this process to help the team reach consensus and refine the codes.The final themes were discussed with the therapists as a form of member checking.No changes to the themes were made as a result of consultation with the therapists.Trustworthiness was enhanced by using a team of coders with diverse backgrounds (2 physical therapists, 1 occupational therapist) and member checking.Trustworthiness of the interpretation of overall findings is strengthened by the convergence of therapist and patient perspectives [28].

Patients
Seventy-seven individuals with PD were offered physical therapy services via telehealth at the BU CNR from 23 March through 30 June 2020.Fifty-five individuals participated in physical therapy via telehealth, twenty-two individuals did not, resulting in a 71.4% participation rate.Participants were mostly White, non-Hispanic, older adult males.Non-participants had similar demographics (Table 1).The largest group of participants were existing patients who had been familiar with the therapists and services at the CNR prior to the COVID-19 shutdown (29/55, 52.7%).Several patients did not respond when contacted (8/22, 36.4%) to offer PT telehealth services (Table 2).For those who were successfully contacted, uncertainty about their ability to use technology for telehealth services for physical therapy (7/22, 31.8%) and the belief that their needs would not be met via telehealth (5/22, 22.7%) (Table 2) were the most common reasons for rejection of PT via telehealth.

Outcome measures
There were five patient-reported outcome measures and six performance-based measures that were administered to patients during remote episodes of care (Table 3).The Parkinson Disease Questionnaire-39 was the most frequently used patient-reported measure (67.3%) and the Five Times Sit to Stand test was the most frequently used performance-based measure (65.5%).Patient-reported measures were more frequently used compared with performance-based measures (group mean, 48.36% vs. 30%, respectively).

Treatment
There was a total of 227 telehealth sessions over the reviewed period, with a mean of 4.4 (SD 3.3) sessions per patient.The range

Safety
No injuries, falls, or unanticipated medical complications occurred during the telehealth treatment sessions according to medical records review and therapist report.

Telehealth patient satisfaction survey
There was an 80% response rate for our patient satisfaction survey.Forty-four of the 55 individuals who participated in PT via telehealth responded.All (100%) patients who completed the survey reported satisfaction (satisfied-very satisfied) with their treatment experience however, when asked to compare their experience with PT via telehealth to in-person PT, satisfaction was reduced to 57% (Table 5).Most patients (90.9%, 40/44) did not have any difficulty setting up the technology for their telehealth session.Over half of the patients (52.27%) had very few or no experiences with a virtual meeting (medical or non-medical) prior to engaging with their physical therapist via telehealth.Eighty percent of patients wanted to continue with PT via telehealth either alone or in combination with in-person visits.Most (82%) patients would recommend the use of PT via telehealth to their friends and family.
Over 61% of individuals cited convenience as a benefit.When patients were asked, "What did you like most about your physical therapy session using telehealth?" (open-ended question on survey), the most common response was convenience (e.g., no commute, no parking, time and energy saving).This sentiment is exemplified by one patient writing, "We didn't have to drive to Boston, park and get upstairs in the elevator-all of which is difficult for me because of my limited mobility."Overall, patients felt the sessions were beneficial, with one patient indicating, I was genuinely surprised at how effective the telehealth approach was.The large screen of a desktop/or iPad combined with the mobility of an iPhone allowed ample discourse plus close-up views as needed.These benefits came with no need to drive into Boston and search for a parking spot.
Other positive aspects of telehealth included accessing expert clinicians, maintaining safety during the COVID-19 pandemic, and the home environment provided targeted treatment to meet personal needs.
When asked, "What did you like least about your physical therapy session using telehealth?", technology problems were reported by 30% (13) of patients.Examples of this were problems with the internet, logging into the meeting platform, and visibility with computer cameras.One patient explained, "It was a little difficult to orient myself in the space relative to the camera in order to ensure [the physical therapist] could make the necessary clinical observations."Several patients indicated that they had no complaints or dislikes with physical therapy via telehealth, and 80% did not provide recommendations to improve the provisions of  [30,31] 52.7% (29) activities specific balance Confidence (abC) scale [32] 41.8% (23) barriers self-efficacy scale (baRse) [33] 41.8% (23) self-efficacy of Walking Duration (seWD) scale [34] 38.2% (21) Performance-based outcome measures Five times sit to stand (5xsts) [35] 65.5% (36) single leg balance [36] 41.8% (23) MDs-UPDRs [37] Part iii (components) 41.8% (23) observational Gait assessment [38,39] 21.8% (12) occiput to Wall [40] 5.5% (3) bridge endurance [41] 3.6% (2) PT via telehealth.Though some noted limitations in assessment, equipment and space availability, and a lack of physical contact as challenges.

Therapists' perspectives
Overall, therapists felt that telehealth enhanced patients' access to PT and that access to the home environment was a benefit.They also reported several factors that influenced delivery of services via telehealth and their satisfaction with this modality.These factors included: usability of technology, limitations in assessment and treatment, and preparation of patients for telehealth.

Access
Therapists explained that PT via telehealth increased access to physical therapy services and therapist's access to the home environment.Telehealth reduced logistical barriers due to reduced travel, effort, fatigue, parking, time, and ease of rescheduling.In addition, geographical constraints were removed, and therapists reported that they were able to see patients that lived farther away more often.One therapist stated, the access to treatment is a lot better, you know.So patients that maybe have issues with… their energy level throughout the course of the day, if I'm seeing them in their house, I can see them and we can do something, …whereas they might call and cancel an appointment because they might not feel well or they might show up 40 minutes late to an hour-long appointment…now I can get them started and it's a lot more convenient for people… In addition, they noted that, telehealth, "gave [patients] more opportunities to be seen at…a higher frequency than they would not have been able to achieve had they been coming into the office."Therapists also consistently implied that these advantages may be more acutely felt in a city, where travel to appointments can include more complex logistics (e.g., public transportation, parking), noting, "it's taken away the stress of commuting…I think the people who adapted well to that would want to continue that way." In addition, telehealth afforded increased therapist access into the patient's home.Therapists reported that the home offers enhanced opportunity for task-specific training.This eliminates the need to simulate the home in the clinic environment.Also, home exercise programs can be individually tailored to the specific environment that the program is intended for.As one therapist shared, In terms of helping somebody set up a home exercise program and be able to see their home, see where they are walking, what their couch looks like, what they are doing their sit to stands on, that component is almost more satisfying than trying to set up a home exercise program in the clinic.
Another therapist commented, "you can get so much more specific in their actual house.So that is, that is another really, another big plus to it for me."Herein, the therapists felt that telehealth services, in a sense, enabled them to provide home-based services they would otherwise never be able to provide.

Usability of technology
Usability of technology was identified as supporting as well as hindering PT via telehealth.Therapists indicated that there were both personal technology issues as well as external factors related to technology that influenced PT services.The personal technology issues were at both the therapist and patient level, for example lack of familiarity with virtual meeting platforms and anxiety related to technology.Unique to patients, symptoms related to fine-motor control (e.g., tremor) interfered with use of technology.External factors that supported this mode of delivery were having a strong internet connection, family member support to manage technology, and access to a computer.One therapist described how she and a patient experienced both personal and external challenges using technology: He had virtual background on…he could not get the virtual background to stop and as much as I coached him, I only know how to do one thing, … go to the whatever tab and then unclick virtual background.I probably coached him on that 15 times and we couldn't get it off … I couldn't see anything around him.
While technology challenges did pose barriers to some patients, having external supports or prior familiarity with technology were facilitators.In addition, most therapists noted that technological challenges resolved with practice.

Limitations in assessment and treatment
Therapists felt limited in assessment and treatment.They reported that PT via telehealth is not easily translated from in-person care and that additional structure and skills are needed.Visualization of movement was identified as being critical for PT services and is often impaired during telehealth sessions, as one PT noted, "it can be like simple observational things.Like whether it's the patient walking into the room, or you're noticing, you can just, have a full view of the patient if you are there in person." Another therapist stated, "some examination, some treatment, like potentially manually or whether it's like you will want to try to enforce like a higher-level balance activity that is restricted by telehealth."Some therapists indicated that there were challenges with interpersonal communication during telehealth interactions, stating, "I think it's hard for some people to feel connected to the computer." Others felt that individuals with vestibular system impairments were not appropriate for physical therapy services via telehealth due to the inherent manual assessment and treatment that is required.One therapist stated, "Yeah because you can't assess it, you can't appropriately figure out which system is involved and therefore how can you treat it?"

Preparations of patients for telehealth
Therapists explained that patients require preparation for PT via telehealth.Therapists indicated that a preparatory technology session before the initial evaluation would improve the efficiency of the PT sessions, for example, I think, maybe having additional sessions before…just the logistics of handling Zoom…how to get the audio on, how to get the camera on… having a second person there to help with managing…the camera.That would just give the patient more time…fully engage on just PT during the session.
Another therapist described having a rehabilitation aide call patients to ensure they could set up the technology.They also suggested the use of tutorials or directions (e.g., "a series of screen shot directions for every device they could think of like a Mac, a PC, and iPad, a phone") on the use of the required technology to reduce frustration and improve troubleshooting.Another recommendation was to use a screening to determine appropriateness for telehealth services.Another noted that appropriateness may change over time, sharing, "I think a decision tree, a screen…let's say it's for balance, it might be more appropriate [to be in person] 2x/week for 3 weeks and then we'll transition to telehealth."Another suggested that an emergency plan is critical in the telehealth environment and that location and emergency contacts need to be verified at each visit.These therapists felt that additional resources and planning were critical, not only to initiate, but also to safely maintain, telehealth services.

Hybrid model of care
In consideration of the above experiences, facilitators, and barriers, therapists advocated for a hybrid model of PT services (a combination of in-person PT and remotely delivered PT via telehealth).One therapist shared, "Perhaps a hybrid model would be the most effective, but if this is an option to continue, even if shutdown were to end, I would want to continue with some people."Others agreed that the advantages of telehealth offered potential to enhance services beyond the public health emergency, noting, "I think a hybrid would probably be the best format to go forward."Another therapist stated, Once you meet someone, once you feel like you have a handle on what is going on, then I think it's absolutely realistic to do telehealth….we've been forced to have only telehealth, but I think as we move in the future, I think hybrid…will be probably ideal, you know, better than doing just one or just the other.
Therefore, therapists expressed a desire to combine the strengths of both delivery modalities to provide services to patients that could be responsive to patients' changing needs.In addition, this final quote highlights the common desire by therapists to have an in-person evaluation upon which telehealth sessions could be developed.

Discussion
The results of this study reveal a high participation rate in PT via telehealth, with similar demographics between those that participated and those that did not.Most outcome measures used were patient reported, however, performance-based measures were also used.Therapeutic exercise was the most common treatment provided during this course of care, not unlike in-person PT services [42].Despite therapists' reported concerns about the safety of remote care, PT via telehealth was safe.However, this is not an unequivocal assessment of safety and PT via telehealth requires continued investigation.There is the potential that therapists were judicious in the intensity and challenge that was provided to patients due to safety concerns when not physically present with the patient.Moreover, although there was a wide range of disease duration within this broad clinical population, it is unclear if PT via telehealth is safe across the range of disease severity and all PD patient presentations.Both patients and therapists found advantages and disadvantages of PT via telehealth.There was a notable reduction in patient satisfaction with PT via telehealth when asked to compare this to in-person PT.Interestingly, this is consistent with a recent survey that similarly found that based upon their recent experiences with physical therapy, 56.9% of people with PD indicated that they were less satisfied with PT via telehealth when compared to in-person PT [15].This dissatisfaction may be rectified with a hybrid model that would address the short-comings of each delivery method while simultaneously profiting from the unique strengths.These findings, along with patient and therapist endorsement of a hybrid model, support the need for further research of physical therapy delivered through a hybrid model for people with PD.
Examining the demographics of participants revealed a general lack of racial and ethnic diversity in our sample with only two individuals who were non-White and no individuals that were Hispanic/Latinx.This is consistent with previous studies describing neurologists' treatment of people with PD via telehealth [17][18][19][20][21] as well as general treatment and utilization disparities for in-person care [43][44][45].This unacceptable and persistent pattern requires clinicians and researchers to improve outreach to underrepresented communities to understand how and if this mode of delivery might improve access to PT services.Ongoing studies are examining methods to improve engagement in research for underrepresented populations in PD [46].
Several critical observations were noted by therapists to help inform future PT via telehealth services.An initial screening by a rehabilitation aide or administrative assistant was recommended to determine internet connectivity in the patient's home, types of devices (smartphone, tablet, desktop/laptop computer, webcams, etc.) available, patient familiarity with required technology, physical space, exercise (e.g., treadmill) and medical equipment (e.g., home blood pressure monitor) available, and amount of family/caregiver support in the home.Each of these factors will influence the therapist's plan of care.For example, for those individuals who are at a high risk of falls, therapists may determine that balance training is feasible only when another person is available in the home to assist with guarding.However, our experiences and the data do not support a widespread recommendation that all physical therapy sessions delivered via telehealth to people with PD should require another person to be physically present.In fact, based upon our data, there were no adverse events that occurred during these episodes of care.Additionally, limiting physical therapy via telehealth only to those that have social support or caregivers in the home may further limit access, increase isolation and a decline in health in this disadvantaged population.The recommendation to have another person present during telehealth sessions was made by the physical therapist following their evaluation of each patient and development of their individualized plan of care.Next, after the screening is complete, preparatory resources are recommended.Preparatory resources could include links or online documents with easy-tofollow instructions and/or meeting with a support person on the rehabilitation team immediately preceding the patient's scheduled therapy session.Several therapists indicated that this preparation reduced therapist burden for technology orientation thereby improving efficiency during the therapy session.Finally, therapists indicated the need to confirm the patient's location and contact information, at each session, in case of an emergency.In the event of an emergency, the patient's physical location and contact information are crucial for a rapid response.
There are numerous tests and measures that are used in the physical therapist's evaluation of people with PD when conducted in person.Therapists in our study chose performance-based outcome measures that could be conducted in a small physical space and observed in front of the stationary video camera, such as the Five Times Sit to Stand test and Single-Limb Balance test.The limitations of the fixed camera often precluded the use of recommended and commonly used outcome measures related to gait, such as the Ten Meter Walk Test or the Six Minute Walk test, which require movement in a large space [47].A recent publication advocates for the use of smartphone applications for neurological exams of people with PD in the telemedicine environment [48], however teleassessment of gait is only in its initial stages of testing and validation [49][50][51][52].Patient-reported outcome measures are an obvious choice in the remote environment, as they can seamlessly provide valuable patient perspectives related to living with PD.Therapists effectively used patient-reported outcome measures, with surveys administered in a secure web application, related to pain, balance confidence, self-efficacy, and quality of life.Ultimately, a balance of patient-reported outcomes and performance-based outcomes that is not limited, but enhanced by technology, will provide a complete assessment of an individual during an initial PT evaluation via telehealth.
Advances in technology as well as efficient implementation strategies are needed to address the difficulties that therapists encounter with outcome assessment via telehealth.The International Parkinson and Movement Disorder Society Task Force on Technology has provided a roadmap to facilitate the implementation of patient-centered outcome measures obtained via mobile health technologies [53].This advancement will support the physical therapist's evaluation and ongoing assessment in the remote environment without sacrificing crucial objective measurement of the patient's health status during PT via telehealth.
This study supports the use of PT via telehealth as a safe, accessible, and satisfactory mode of delivery, suggesting that PT delivered via telehealth should be considered on a permanent rather than temporary basis.However, we did not collect data on patient outcomes and further research is needed to determine whether PT delivered via telehealth is equally efficacious as in-person PT.The current approvals by the Center for Medicare and Medicaid Services that permitted PT via telehealth during the public health emergency have demonstrated the demand and necessity for this type of service.The Expanded Telehealth Access Act, that is currently under consideration in Congress, would permit reimbursement by Medicare for PT via telehealth permanently [54].As noted, studies suggest underrepresented populations with PD underutilize healthcare services.Telehealth may play a critical role to reduce financial and time barriers that have been reported by underrepresented populations as limiting engagement with research and physical therapy services [55][56][57].However, the presence of telehealth alone, without outreach, education, and cultural adaptation to underrepresented populations, will not automatically create these bridges [58].
There are several limitations that must be considered when interpreting our results.This examination was limited to one university-based outpatient rehabilitation center in an urban environment which may limit generalizability.In addition, factors related to commuting into an urban university environment may not be applicable to local community clinics.The COVID-19 pandemic itself may have affected satisfaction with this method of delivery as the options for care were restricted.This study was not focused on the effectiveness of PT via telehealth for people with PD and this warrants further investigation.

Conclusions
Our results suggest that PT via telehealth for patients with PD is acceptable to patients and physical therapists.This mode of delivery of PT services was safe for people with PD in our sample.Although PT via telehealth was well received in this study, availability and benefits may not reach all populations equitably.When presented with the option to participate in PT via telehealth, participation is high.The use of outcome measurement and treatment interventions are comparable to in-person practices, however future studies with representative samples are needed to establish efficacy.

Table 2 .
Reasons reported for non-participation in Pt via telehealth.Only four patients received treatment that was focused on functional activity training.Typically, therapeutic exercise and balance training occurred with the patient set up in a supported environment (e.g., standing in front of a kitchen counter or sturdy piece of furniture for anterior support and/or a chair or support person behind them).Balance training included progressive challenges with reduction of the base of support, increased excursion of the center of mass beyond the base of support, and multi-directional stepping.Gait training was conducted with the patient in the open spaces that were available in their homes (hallways, garage, driveway, kitchen).If the therapist determined that another person was required to guard the patient, gait training only occurred with another person present.Otherwise, gait training via telehealth was similar to in-person training with auditory and verbal cues to guide amplitude, rhythm, speed, and obstacle negotiation.

Table 3 .
Use of outcome measures during Pt via telehealth.

Table 4 .
treatments used during Pt via telehealth.

Table 5 .
Patient satisfaction with Pt via telehealth.