Research Articles
Physical Activity Coaching via Telehealth for People With
Parkinson Disease: A Cohort Study
Hai-Jung Steffi Shih, PT, PhD, Chelsea E. Macpherson, PT, DPT, NCS, Miriam King, MA,
Elizabeth Delaney, LCSW, Yu Gu, PT, PhD, Katrina Long, MS, OTR/L, EdD,
Jennifer Reid, PT, DPT, NCS, Julie Fineman, PT, EdD, Geraldine Yu, PT, DPT, OCS, Jamie Rieger, BA,
Ashrita Satchidanand, MA, Hiral Shah, MD, Roy N. Alcalay, MD, and Lori Quinn, PT, EdD, FAPTA
Background and Purpose: Physical activity (PA) has many known
benefits for people with Parkinson disease (PD); however, many
people do not meet recommended levels of frequency or inten-
sity. We designed Engage-PD, a PA coaching program delivered
via telehealth and grounded in self-determination theory to pro-
mote PA uptake and facilitate exercise self-efficacy in people with
Parkinson disease. This study aimed to determine the feasibility and
preliminary efficacy of Engage-PD, and to explore whether baseline
characteristics were associated with outcomes.
Methods: A single cohort of people with PD (n = 62, Hoehn and
Yahr I-III) participated in the 3-month Engage-PD program, which
consisted of up to 5 telehealth coaching sessions delivered by phys-
ical therapists. Feasibility was evaluated based on recruitment and
retention rates, along with participants’ feedback. Planned and un-
planned PA, exercise self-efficacy (ESE), and individualized goals
were assessed pre- and post-intervention. Relationships between
baseline characteristics and changes in planned PA and ESE were
also evaluated.
Department of Biobehavioral Sciences, Teachers College, Columbia Univer-
sity, New York, New York (H.J.S.S., C.E.M., M.K., Y.G., A.S., L.Q.);
Departments of Neurology (E.D., H.S., R.N.A.) and Rehabilitation and
Regenerative Medicine (Physical Therapy) (L.Q.), Columbia University
Irving Medical Center, New York, New York; Department of Occupa-
tional Therapy, San Jose State University, San Jose, California (K.L.);
Department of Rehabilitation (Physical Therapy), New York Presbyterian
Hospital, New York, New York (J.R., G.Y.); Doctor of Physical Therapy
Program, Marist College, Poughkeepsie, New York (J.F.); and Department
of Neuroscience, Barnard College of Columbia University, New York, New
York (J.R.).
This project was funded by the Parkinson’s Foundation community grant year
2019-2021.
Part of this work was presented in the Movement Disorders Society Congress
in 2020 and 2021, and the Academy of Neurologic Physical Therapy
Annual Conference in 2021.
ClinicalTrials.gov registration number: NCT049222190.
The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jnpt.org).
Correspondence: Lori Quinn, PT, EdD, FAPTA, Department of Biobehav-
ioral Sciences, Teachers College, Columbia University, New York, NY
10024 (lq2165@tc.columbia.edu).
Copyright © 2022 Academy of Neurologic Physical Therapy, APTA.
ISSN: 1557-0576/22/4604-0240
DOI: 10.1097/NPT.0000000000000410
240
Copyright © 2022 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Results: Recruitment (62%) and retention (85%) rates were high,
and the intervention was well accepted and perceived by the partici-
pants. From pre- to postintervention, participants increased planned
PA (d = 0.33), ESE (d = 1.20), and individualized goal perfor-
mance (d = 1.63) and satisfaction (d = 1.70). Participants with
lower baseline planned PA experienced greater improvements in
planned PA, and those with lower baseline ESE experienced greater
improvements in ESE.
Discussion and Conclusions: A telehealth PA coaching program
for people with PD was feasible and potentially efficacious. Phys-
ical therapist-led coaching may be an important component of a
consultative model of care starting early in the disease process.
Video Abstract available for more insights from the authors (see the
Video, Supplemental Digital Content 1, available at: http://links.lww.
com/JNPT/A393).
Key words: behavior change, coaching, exercise, Parkinson disease,
physical activity
(JNPT 2022;46: 240–250)
INTRODUCTION
T he management of neurodegenerative diseases such as
Parkinson disease (PD) requires consideration of chang-
ing needs and functional abilities at different disease stages.
Traditional models of care place less emphasis on starting
rehabilitative therapy soon after diagnosis, which is incon-
gruent with current evidence that physical activity (PA)
can delay neurodegeneration and potentially modify disease
progression.1,2 A recent framework suggested incorporating
consultative, proactive therapy for evaluation, education, and
advice starting in early disease stage.3 In consultative roles at
this stage, physical therapists promote PA, encourage disease
self-management, and address secondary prevention in efforts
to delay the onset of activity limitations.4 Early intervention
for people with PD can empower them to harness long-term
benefits of PA and self-management.5
The unique and powerful role of PA—especially ex-
ercise (structured PA for health benefits)—in improving
function and health outcomes in people with PD is widely
demonstrated. Studies have shown that exercise improves
motor performance, physical and cognitive function, and
quality of life in people with PD.6-9 Furthermore, there is
JNPT • Volume 46, October 2022
JNPT • Volume 46, October 2022 Physical Activity Coaching via Telehealth for People With Parkinson Disease
promising evidence that aerobic exercise and PA have the po-
tential to modify disease progression.8-11 Exercise may have
neuroprotective effects via mechanisms within the central ner-
vous system that facilitate synaptogenesis, neurogenesis, and
neurotransmitter synthesis.12,13 Symptom improvements may
result from increases in cortical excitability, substantia nigra,
and prefrontal brain activity after exercise in PD.13,14
Despite the many benefits of PA, individuals with PD
face general and disease-specific barriers to exercise. General
barriers include low health literacy,15 lack of motivation,16
lack of time,16 and the associated costs and transportation
challenges.17 Additionally, disease-specific barriers such as
fatigue, balance impairments, and mood disorders may pre-
vent people from participating in PA.18 These barriers may
explain why people with PD exercise less than the general
population,19 and only 27% meet recommended levels of 150
minutes of moderate PA or 75 minutes of vigorous PA per
week.20-22 The COVID-19 pandemic and the stay-at-home
restrictions further increased barriers to exercise.23-25
Coaching to promote PA is an integral part of the con-
sultative therapy model of care, and it is also well-suited for
telehealth delivery.26,27 Physical therapists are training in mo-
tivational interviewing-style techniques and have expertise
in exercise and PD management. Therefore, they are well-
positioned to deliver PA coaching and consultation starting
in early disease stages. Growing research in this area has led
to studies using mobile health technology, home-based ex-
ercises, and coaching or peer coaching to promote exercise
uptake in neurodegenerative diseases.28-34 While these trials
showed promising results, many studies introduce exercise in
a prescriptive manner (prescribing exercise modality, dura-
tion, frequency, and intensity) and rely on extrinsic feedback
(such as mobile apps). The lack of autonomy in goal-setting
and exercise modality and the extrinsic nature of feedback
may limit the facilitation of intrinsic motivation for long-term
exercise adherence.
Engage-PD, a 3-month telehealth coaching interven-
tion, was developed after a pilot study with similar design
demonstrated the feasibility of PA coaching intervention in
PD.35 The intervention was grounded in self-determination
theory36 to facilitate intrinsic or highly autonomous moti-
vation for long-term PA uptake in people with PD.26 The
intervention is defined using a logic model26 and uses be-
havior change techniques to engage people with early-stage
PD to participate in PA as a disease self-management strat-
egy. Engage-PD is grounded in self-determination theory to
satisfy 3 basic psychological needs—autonomy, relatedness,
and competence—to increase exercise self-efficacy for long-
term PA sustainability.37-40 Autonomy is supported through
participant-centered goal-setting and choice of exercise
modality; relatedness is supported through participant-
interventionist interactions and encouragements; competence
is supported through experiencing success in overcoming
barriers and reaching goals. Through the coaching process,
we aim to increase exercise self-efficacy—people’s belief in
their capacity to perform exercise and overcoming barriers
to exercise—a significant factor related to initial exercise
uptake and long-term exercise adherence.40 Harnessing the
self-determination theory, the program addresses barriers to
© 2022 Academy of Neurologic Physical Therapy, APTA
Copyright © 2022 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
exercise and supports progress toward goals that are purpose-
ful and meaningful to participants. In addition, a telehealth
delivery may increase accessibility and reduce costs for
neurological populations.41,42
The primary purpose of this single cohort study was to
determine the feasibility and preliminary efficacy of Engage-
PD, a PA coaching program for people with PD delivered
via telehealth. The secondary purpose was to explore whether
participant characteristics at baseline were associated with
changes in exercise self-efficacy and PA uptake. We expected
that younger age and lower baseline levels of PA would be
associated with more improvements in outcome measures
post-intervention for people with PD.
METHODS
Participants
A single cohort of participants were recruited between
March 2020 and March 2021 from Columbia University
Irving Medical Center Parkinson’s Foundation Center of
Excellence in New York, New York. Potential participants
were referred by movement disorder specialists and a phone
screening session was used to assess eligibility and inter-
est. Participants were included if they were between the
ages of 18 and 85 years, had a neurologist-confirmed di-
agnosis of idiopathic PD between Hoehn and Yahr (H&Y)
stages I and III, were ambulatory for indoor and outdoor
mobility without assistance or use of assistive devices, and
either successfully completed the Physical Activity Readiness
Questionnaire (PAR-Q)43 or received medical clearance to ex-
ercise from a medical doctor. Participants were excluded if
they had coexisting neurological or musculoskeletal condi-
tions that would restrict exercise. They were also excluded
if they already had more than 150 minutes of moderate to
vigorous PA per week. All participants provided electronic in-
formed consent approved by the institutional review boards at
Teachers College, Columbia University, and Columbia Uni-
versity Irving Medical Center. This trial has been registered
on ClinicalTrials.gov (NCT049222190).
Intervention
The Engage-PD intervention consists of up to 5 per-
sonal coaching sessions delivered via telehealth, over a
3-month period.26 The number and frequency of the coach-
ing sessions were determined based on individuals’ needs
and progress, with the typical interval between sessions start-
ing from 2 weeks and gradually increased to 4 to 6 weeks.
The coaching intervention was led by licensed physical ther-
apists using Zoom Video Communications, Inc (San Jose,
California). Sessions were scheduled at participants’ conve-
nience and each session consisted of individualized coaching
activities (Table 1). Engage-PD is grounded in the self-
determination theory44 and focused on promoting individual
autonomy, competence, and relatedness to improve PA and ex-
ercise uptake.26,33,45 Therapists worked with participants to
build multimodal programs incorporating aerobic, strength-
ening, balance, and flexibility exercises, with an emphasis on
moderate- to high-intensity aerobic exercise at a minimum of
3 times per week and a total of 150 minutes.21,22
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Shih et al JNPT • Volume 46, October 2022

Table 1. Overview of Engage-PD Intervention

Session Activities
Session 1 (within 2 wk of 1. Introduce the participant to the program, and the Engage-PD Physical Activity Workbook.
baseline assessment) 2. Engage-PD Physical Activity Workbook Sections 1-4.
3. Introduce to mCOPM and ask the participant to consider goals for next session.
4. Discuss means of tracking PA (ie, written log or PA monitor).
5. Summarize meeting and review upcoming plan.
Session 2 1. Review PA log/data since the last session.
2. Review Sections 5-8 of the Engage-PD workbook
3. Discuss and finalize goals.
4. Begin instruction in physical activity/exercise program as appropriate.
5. Summarize meeting and review upcoming plan.
Sessions 3-4 1. Review PA log/data and adjust goals as necessary.
2. Discuss barriers and strategies for physical activity uptake.
3. Review instruction in physical activity/exercise program as appropriate.
4. Summarize meeting and review upcoming plan.
Last session 1. Review PA log/data.
2. Review and score goals.
3. Review instruction in physical activity/exercise program as appropriate.
4. Discuss barriers and strategies for sustained physical activity uptake.
5. Summarize meeting and review upcoming plan.
Abbreviations: PA, physical activity; mCOPM, modified Canadian Occupational Performance Measure.
Engage-PD workbook chapters: 1. Exercise, who me? 2. Let’s get moving! 3. Overcoming challenges. 4. Safety and monitoring. 5. Developing a physical activity plan. 6. Goals
and targets. 7. Recording your activities and progress. 8. My physical activity plan.

Six physical therapists who were trained in PA coach-
ing delivered the intervention. Therapists were provided a
detailed coaching manual, and underwent training on moti-
vational interviewing techniques, goal setting, and promotion
of self-determination theory themes. Training consisted of a
2-hour video and at least 2 observational sessions with an
experienced therapist. Therapists worked with participants to
establish individualized goals, using the modified Canadian
Occupational Performance Measure (mCOPM).46,47 Thera-
pists provided guidance on overcoming motivational, social,
physical, and environmental barriers to PA. Participants chose
exercises and physical activities that were meaningful and
enjoyable to them, and specific recommendations on exer-
cise modifications and symptom management were provided
by the therapists. Examples of exercise modality that par-
ticipants chose included walking, running, stationary biking,
yoga, and virtual fitness and dance programs available through
community organizations online. Advice on exercise modifi-
cations was tailored based on participants’ functional ability
and fitness level. Moderate- to high-intensity exercise was de-
termined as 55% to 85% maximum heart rate based on the
220 − age formula,48 although the usage of this formula may
be adjusted based on individual conditions, such as taking
β-blockers. Participants monitored their heart rate by tak-
ing their pulse or using available wearable devices. When
heart rate monitoring was less feasible, they used the modified
Borg rating of perceived exertion to achieve a general target
in the moderate-/high-intensity range. We used a conserva-
tive range of 3 to 6 out of 10 (moderate intensity); however,
the recommendation was individualized based on participant
ability and if able participants were encouraged to achieve
vigorous intensity of 7 to 8. Therapists guided individuals
through exercise progressions based on existing guidelines,49
but the goals set for progressions were individualized and au-
tonomous. Therapists used a standardized approach to help
participants set goals—identify current state, identify end goal
at 3 months, and determine the next achievable step in the
short term. Additionally, therapists provided training on safety
and monitoring during exercise, and engaged care partners
when necessary.
Participants also received a disease-specific workbook
that was reviewed and referenced by their therapist at the be-
ginning of the sessions and throughout the intervention. The
workbook was developed after piloting in a previous study,35
and included evidence-based recommendations for exercise
pertaining to frequency, intensity, and duration for categories
of aerobic, strengthening/resistance, flexibility, and neuromo-
tor exercises.50,51 The workbook also provides education on
PA monitoring by using high- or low-tech options such as
wearable activity monitors, smartphones, or exercise diaries,
which can help support autonomy.
Outcome Assessments
All baseline and postintervention outcome assessments
were carried out over Zoom by the study coordinator and
the therapists. Baseline assessments, including the Brunel
Lifestyle Inventory,52 the Exercise Self-Efficacy Scale,53,54
and the mCOPM,46,47 were conducted within 2 weeks prior
to the first coaching session. Postintervention assessments,
including all measures from the baseline assessment and
an additional exit questionnaire to assess feasibility and
participant perspectives, were conducted by the study coor-
dinator a week after the last coaching session had ended at 3
months. When administering the questionnaires, the therapist
or study coordinator read each question and ensured that
the participants fully understood them before recording their
answers.

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JNPT • Volume 46, October 2022 Physical Activity Coaching via Telehealth for People With Parkinson Disease
Feasibility
Recruitment. Recruitment rate was calculated as the
percentage of referred participants from the neurologists who
signed the consent form and enrolled in the study.
Retention. Retention rate was calculated as the per-
centage of enrolled participants who completed posttest
assessments.
Adverse Events. Any new adverse events were doc-
umented by the therapists during the coaching sessions and
reported to the research team.
Acceptability. A customized postintervention ques-
tionnaire was administered by the study coordinator to assess
participants’ acceptability of the intervention.55 The question-
naire consisted of 26 Likert scale questions (1 = strongly
disagree to 5 = strongly agree, example question: “I felt sat-
isfied with the visits from my therapist.”). Questions were
categorized into 4 domains: overall intervention satisfaction,
therapist interaction, workbook, and self-efficacy.
Participant Perspectives. Ten open-ended questions
were asked to gain insight into participants’ perspectives of
the intervention (such as “what were some tools/benefits you
gained from this experience that you did not expect?”).
Intervention Outcomes
Physical Activity. The Brunel Lifestyle Inventory
(Brunel) is a 10-item questionnaire that measures both
planned and unplanned PA.52 Planned PA is defined as any ac-
tivity that is scheduled, which may enhance health, fitness, or
well-being (eg, brisk walking, cycling and team games), thus
is conceptually similar to exercise. Unplanned PA is any form
of PA that is excluded from planned PA (eg, heavy house-
work, climbing stairs, walking or cycling to work, gardening,
shopping, and playing with children). The questionnaire was
determined to have reasonable concurrent validity (r = 0.11-
0.64) in a sample of healthy young adults.52,56 The test-retest
reliability in our cohort of 14 participants with PD was good:
planned PA, intraclass correlation coefficient (ICC)(2,1) =
0.77 (95% confidence interval [CI] = 0.42, 0.92); unplanned
PA, ICC(2,1) = 0.80 (95% CI = 0.49, 0.93) (L Quinn et al,
unpublished data, 2021).
Exercise Self-Efficacy. The Exercise Self-Efficacy
Scale (ESE) is an 18-item test that measures an individual’s
self-efficacy to participate in exercise when social and phys-
ical barriers are present.53,54 Participants were asked to rate
a 5-point Likert scale for confidence to exercise regardless
of barriers, with “1” meaning “not at all confident” and “5”
meaning “completely confident.” The ESE has been used in
previous PD research and was sensitive to change,57 and the
test-retest reliability in a cohort of 14 participants with PD
was good: ICC(2,1) = 0.80 (95% CI = 0.49, 0.93) (L Quinn
et al, unpublished data, 2021).
Participant Goals. The mCOPM46,47 is a tool used
to evaluate perceived performance, satisfaction, and impor-
tance of individualized goals. The mCOPM is also a tool
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Copyright © 2022 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
for initiating conversation about challenges faced in everyday
living, which provides the basis for setting PA intervention
goals. As such, when participants mentioned symptoms (such
as constipation) or general mobility issues that they would
like to address, therapists guided participants to set PA goals
that may help address these issues (such as improved gut
motility). Each individualized goal on the mCOPM is ranked
on a 10-point scale, where “1” indicates the lowest level of
performance, satisfaction, or importance, and “10” indicates
the highest. We only analyzed the performance and satis-
faction subscores for the purpose of this study. The original
COPM questionnaire has been validated in the general and
neurological populations.58
Statistical Analysis
Descriptive statistics were performed on participants’
characteristics. We calculated recruitment and retention as
percentages and calculated average score in each domain from
the postintervention questionnaire. Missing data were ex-
cluded from the preliminary efficacy analyses. We determined
the effect estimates for the pre-post difference of Brunel
planned and unplanned PA scores, ESE, and mCOPM per-
formance and satisfaction scores. The distribution of these
variables was plotted and inspected for normality. The 95%
CI of mean difference, Cohen’s d, and 95% CI of Cohen’s d
were calculated. We chose to use an estimation method for
statistical inference instead of null hypothesis testing (using
P values) to provide more information about the size of the
effects and to avoid drawing misleading conclusions.59
We also explored relationships between participant
baseline characteristics and pre-post changes in 2 important
outcomes—Brunel planned PA and ESE. Pearson’s r was used
to determine the strength of the association between age,
baseline Brunel planned PA, and baseline ESE in relation
to the pre-post changes in Brunel planned PA and ESE af-
ter missing data were excluded (Figure 1). Cohen’s d was
used to determine the effect of sex on the pre-post changes
in Brunel planned PA and ESE. Kendall’s τ b was used
to determine the association between H&Y levels and the
pre-post changes in Brunel planned PA and ESE. We inter-
preted Cohen’s |d| = 0.2, 0.5, and 0.8 as small, medium, and
large effect sizes, respectively.60 Pearson’s |r| = 0.3, 0.5, and
0.7 were interpreted as a small, moderate, and large effect,
respectively.61 Cutoffs for interpreting Kendall’s τ b have not
been established; therefore, we will interpret the strength of
the relationship without predetermined values.
RESULTS
Feasibility
Recruitment and Retention
Participants were recruited between March 24, 2020,
and March 16, 2021, and all posttest assessments were
concluded by June 22, 2021 (Figure 1). A total of 92 patients
were referred and 62 were enrolled, resulting in a 67%
recruitment rate. A total of 53 participants completed the
posttest assessment, resulting in a retention rate of 85%.
The majority of the participants enrolled were White and
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Shih et al
Figure 1. CONSORT diagram, modified to represent our single cohort. This figure is available in color online (www.jnpt.org).
had at least a college education (Table 2). There were no
standardized number of sessions due to the individualized
design of the intervention; however, participants completed
an average (SD) of 3.94 (0.93) sessions, with an average
(range) session length of 60 (30-80) minutes.
Adverse Events
There were no adverse events reported throughout the
intervention period. Around half of the participants had a
care partner involved in their coaching process for general
encouragement and safety monitoring.
Acceptability
The intervention was well accepted and perceived by
the participants. The average score for overall intervention
satisfaction was 4.85 (95% CI = 4.77, 4.93) out of 5; for ther-
apist interaction was 4.97 (95% CI = 4.95, 4.99) out of 5; for
the workbook was 3.54 (95% CI = 3.31, 3.77) out of 5; for
self-efficacy was 4.85 (95% CI = 4.79, 4.91) out of 5.
Participant Perspectives
Responses to the open-ended questions revealed that
motivation, mood, weather, and other commitments were the
top barriers that kept participants from engaging in regu-
lar exercise. Common motivations to join the study included
interest in learning alternative strategies to manage PD, refer-
244
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JNPT • Volume 46, October 2022
ral from a specialist, and searching for alternative therapies
during the COVID-19 pandemic. Fifty-four percent of partic-
ipants indicated they would have not joined the intervention
if virtual sessions were not an option. Participants appreci-
ated the informative communication and support from the
therapists. Therapists’ knowledge on PD, exercise resources,
and goal setting strategies were highly valued by participants.
Participants’ intended to continue working toward the goals
set in the program and develop future exercise plans. There
was a mixed response to using technology in the program.
While most participants found the virtual sessions and online
resources to be accessible, some participants had difficul-
ties using Zoom and other exercise-related applications. To
reduce technological barriers and increase the sense of con-
nectedness, participants commonly suggested it would have
been beneficial to have 1 or 2 in-person sessions to enhance
program delivery.
Intervention Outcomes
Physical Activity
There was an improvement in mean Brunel planned PA
scores from pre- to postintervention with a small effect size
(Table 3 and Figure 2). There was also an increased Brunel
unplanned PA score with a medium effect size (Table 3 and
Figure 2).
© 2022 Academy of Neurologic Physical Therapy, APTA
JNPT • Volume 46, October 2022 Physical Activity Coaching via Telehealth for People With Parkinson Disease

Table 2. Participant Characteristics at Enrollment tionally, there were no apparent influences of sex, H&Y levels,
(n = 62): Mean ± SD or Counts (Percentage) Reported or time since diagnosis on the changes in outcomes (Table 4).
Age, y 65.4 ± 9.2 DISCUSSIONS
Sex
Male 39 (62.9%) We conducted a single cohort study to examine the
Female 23 (37.1%) feasibility and preliminary efficacy of Engage-PD, a tele-
Weight, kg 73.6 ± 14.2 health PA coaching program for people with PD. Our findings
Height, cm 172.0 ± 8.9 showed that the Engage-PD program, conducted during the
Race/ethnicity
White 53 (85.5%)
first year of the COVID-19 pandemic, had high recruitment
Black/African American 3 (4.8%) and retention rates and was well accepted and perceived by
Hispanic 1 (1.6%) a cohort of participants with early-to-mid stage PD. In ad-
Asian 0 (0%) dition, participants increased their planned and unplanned
Other 2 (3.2%) PA, ESE, and performance and satisfaction scores regard-
Declined 3 (4.8%)
Education ing personalized goals with small to large effect sizes. We
High school 2 (3.2%) also explored the relationship between participant charac-
College 25 (40.3%) teristics at baseline with observed changes in ESE and PA
Associates 2 (3.2%) uptake after the intervention. Lower baseline planned PA was
Masters 15 (24.2%)
Doctorate 5 (8.1%)
strongly associated with greater improvements in planned PA,
Other advanced degree 7 (11.3%) whereas lower baseline ESE was strongly associated with
Unknown 6 (9.7%) greater improvements in ESE.
Missing 6 (9.7%) The intervention was feasible and well-accepted by
H&Y participants. Although intervention components differed, our
Stage I 16 (25.8%)
Stage II 25 (40%) high retention rate and no adverse events were similar to pre-
Stage III 21 (34%) vious coaching studies with remote exercise programs.28,29,32
Time since diagnosis, y 4.7 ± 4.3 Among the feedback we received, participants were most sat-
MDS-UPDRSa 25.9 ± 4.1 isfied with the positive interactions with the therapist. By
MoCAb 23.4 ± 12.9
providing individualized coaching sessions, the intervention
Abbreviations: H&Y, Hoehn and Yahr; MDS-UPDRS, Movement Disorders addressed multiple barriers to engage in PA reported by
Society-Unified Parkinson’s Disease Rating Scale (maximum score 199 indicating worst
disability from Parkinson disease); MoCA, Montreal Cognitive Assessment (maximum
people with PD in the literature.15,17,62,63 Participants ac-
score 30 indicating intact cognition). knowledged that the intervention provided useful insights on
a
Data from only 42 participants due to availability of MDS-UPDRS on medical knowledge of appropriate exercise, addressing the social as-
history.
b
Data from only 18 participants due to availability of MoCA on medical history.
pects of exercise and motivation to exercise regularly. The
Engage-PD workbook provides education and guidance for
therapists and participants to engage in discussions related to
exercise especially during the first couple coaching sessions,
Exercise Self-Efficacy and it may be most helpful for those who have lower health
There was an improvement in mean ESE from pre- literacy. As participants become familiar with the workbook
to postintervention with a large effect size (Table 3 and contents, emphasis is shifted to therapist-participant interac-
Figure 2). tions and collaborative problem-solving—which may explain
why the workbook was not as well-perceived by participants.
Participant Goals This highlights the importance of motivational coaching: de-
There was an increase in mean performance and spite lack of knowledge being a common barrier for exercise
satisfaction scores for individualized goals from pre- to engagement,63 addressing knowledge alone is not enough
postintervention with large effect sizes (Table 3). to promote PA.44 Our intervention used coaching grounded
in self-determination theory to address multiple aspects of
Relationship Between Baseline Characteristics the behavior change process to promote long-term PA up-
and Outcomes take beyond the completion of intervention. The emphasis on
After excluding missing data, we explored the rela- therapist-participant interaction and autonomous goal setting
tionship between baseline characteristics and the change is in contrast with other studies that have used mobile health
in Brunel planned PA and ESE (Table 4). Contrary to our to prescribe and monitor remote exercise programs.28-32
expectations, there was no relationship between age and the Coaching is well-suited to be delivered via telehealth,
change in Brunel planned PA (Figure 3A), or change in ESE and may decrease the barriers in transportation and time.26
(Figure 3B). On the other hand, there was a strong relationship Using telehealth to deliver the intervention was crucial for
indicating participants with lower baseline Brunel planned PA recruiting the majority of the participants, which highlights
experienced greater improvements in Brunel planned (Figure the potential of telehealth to increase the accessibility of care
3C), and that participants with lower baseline ESE experi- for people with chronic diseases. A recent study by Flynn
enced greater improvements in ESE (Figure 3D). This was and colleagues64 also demonstrated feasibility for telehealth-
consistent with our expectations that lower baseline PA levels delivered exercise programs for people with PD. However,
would be associated with greater improvements in PA. Addi- in our study, many participants noted they would prefer to

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Shih et al JNPT • Volume 46, October 2022

Table 3. Mean Difference and Effect Sizes Pre- and Post-intervention

Difference
Pre Post Post-Pre 95% CI of Effect Size 95% CI of
Variable n (Mean ± SD) (Mean ± SD) (Mean ± SD) Difference Cohen’s d Effect Size
Brunel planned PA 52 3.86 ± 0.93 4.11 ± 0.55 0.25 ± 0.81 0.03, 0.49 0.33 −0.058, 0.73
Brunel unplanned PA 52 2.32 ± 0.76 2.70 ± 0.69 0.38 ± 0.77 0.16, 0.60 0.52 0.12, 0.91
Exercise self-efficacy 52 56.00 ± 18.04 74.60 ± 12.29 18.81 ± 16.06 14.34, 23.28 1.20 0.78, 1.63
mCOPM—performance 50 4.12 ± 2.00 7.06 ± 2.25 3.26 ± 2.68 2.49, 4.02 1.63 1.17, 2.09
mCOPM—satisfaction 50 3.97 ± 2.02 6.93 ± 2.16 3.29 ± 2.68 2.53, 4.05 1.70 1.23, 2.16
Abbreviations: Brunel, Brunel Lifestyle Inventory; CI, confidence interval; mCOPM, modified Canadian Occupational Performance Measure; PA, physical activity; SD, standard
deviation.

have some in-person components integrated into the pro-
gram, suggesting that a hybrid model may be beneficial to
increase connectedness and incorporate hands-on instructions
while maintaining the ease of access provided by a telehealth
approach.
There were large effect sizes on the changes in mCOPM
and ESE scores, and small to medium effects for PA uptake
following the intervention. Results from the mCOPM, simi-
lar to other forms of goal setting, are subject to participant
bias. However, participants in our study identified specific,
measurable outcomes related to individualized PA uptake.
Self-efficacy is thought to be an important mediator to last-
ing PA behavior change,39,40 and the large effect size seen
in this study is encouraging. This finding may suggest that
participants have a high chance of continuing PA after the
study ends. It is also important to note that, even without a
standardized exercise prescription in Engage-PD, participants
demonstrated increase in self-reported PA that is consistent
with previous reports of increased self-reported or objective
PA in remote exercise management programs.28,29,31 While
the effect size for planned PA was smaller than unplanned PA,
we believe this may have been due to a ceiling effect for our
participants (57% of our participants scored ≥4 out of 5 for
baseline planned PA). Alternatively, the greater effect on un-
planned PA may reflect that coaching increased participants’
awareness to incorporate more unplanned PA in their daily
activities.
Interventions are not “one-size-fits-all,” and the ex-
ploratory analyses in this study may help determine the
subgroups of people who will most benefit from telehealth PA
coaching. Individuals with lower baseline planned PA levels
saw greater increases in planned PA levels after the interven-
tion; likewise, ESE increased more in individuals with lower
baseline ESE. These construct-specific relationships suggest
planned PA levels and ESE are independently modulated, and
that the Engage-PD intervention may help improve both con-
structs, especially in people who start off with lower scores.
People who have a higher baseline PA levels or ESE also re-
ported perceived benefits, which may not have been captured
by the assessments that we used due to potential ceiling ef-
fects. Interestingly, we did not see a relationship between age,
H&Y stages, and time since diagnosis with the outcomes.
Thus, it is possible that Engage-PD may be similarly helpful in
improving self-reported PA for people in later disease stages
with more severe disabilities.65 In fact, there is a relationship
trend indicating that people who are older may improve more
in ESE. This further illustrates that the benefits of Engage-PD
are not exclusive to the younger, more technologically literate
cohort.
Limitations
Results of this study should be interpreted with some
limitations in mind. This single cohort study has inherent lim-
itations in study design—no control group and no blinding
of the participants, therapists, or outcome assessors. This de-
sign was sufficient to determine feasibility and preliminary
efficacy of the intervention, but a fully powered randomized
controlled trial in the future is necessary to draw conclu-
sions about effectiveness. Furthermore, we did not include
any objective measures of PA such as accelerometry data,

Figure 2. Pre- and postintervention Brunel planned physical activity and exercise self-efficacy scores. PA, physical activity. This
figure is available in color online (www.jnpt.org).

246 © 2022 Academy of Neurologic Physical Therapy, APTA

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JNPT • Volume 46, October 2022 Physical Activity Coaching via Telehealth for People With Parkinson Disease

Table 4. Exploratory Relationships Between Baseline Characteristics and Outcomes (n = 55 Analyzed)

Effect Size vs Change in Brunel vs Change in Exercise
Variables Statistics Planned PA 95% CI Self-Efficacy 95% CI
Age Pearson’s r − 0.076 −0.34, 0.20 0.22 −0.05, 0.46
Sex (male vs female) Cohen’s d − 0.07 −0.64, 0.50 − 0.20 −0.77, 0.38
Hoehn and Yahr Kendall’s τ b 0.0019 −0.23, 0.23 0.079 −0.14, 0.30
Time since diagnosis Pearson’s r 0.14 −0.14, 0.40 0.071 −0.21, 0.34
Baseline Brunel Pearson’s r − 0.81 −0.80, −0.70 − 0.26 −0.50, 0.010
planned PA
Baseline exercise Pearson’s r − 0.12 −0.38, 0.16 − 0.75 −0.85, −0.60
self-efficacy
Abbreviations: Brunel, Brunel Lifestyle Inventory; CI, confidence interval; PA, physical activity.

and therefore recognize that self-reported PA measure may
not adequately represent true PA behavior.66 Therefore, future
studies should incorporate objective PA measures when possi-
ble to provide a more direct insight into PA uptake. In addition,
a ceiling effect with the Brunel Lifestyle Inventory may have
limited the amount of improvements that could be detected.
This study did not include individuals with H&Y levels IV
or V, or those who use assistive devices due to safety con-
cerns; however, given the potential benefits of increased PA
in this population, future trials should expand to those with

Figure 3. Relationships between baseline characteristics and outcomes. Blue dots indicate data points; black lines indicate the
least square line to represent trends. PA, physical activity; ESE, exercise self-efficacy. This figure isavailable in color online
(www.jnpt.org).

© 2022 Academy of Neurologic Physical Therapy, APTA 247

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Shih et al
more severe physical impairments and those who use assis-
tive devices where appropriate. Additionally, since Montreal
Cognitive Assessment was only available for 18 out of 62 par-
ticipants, we were not able to determine the effect of cognitive
impairments on this remote coaching program although we
anticipate some difficulties with implementation if cognitive
impairment is severe.65
Our participant sample was predominantly White and
the majority had higher than a college level of education,
which may limit the generalizability of our findings. This is
particularly important since individuals with PD who belong
to a racial or ethnic minority community or have low so-
cioeconomic status are more likely to be diagnosed later,67
have inadequate access to specialist care,68 and are less likely
to exercise or participate in physical therapy.69 Additionally,
those with a lower socioeconomic status may have greater
barriers accessing PA infrastructure, such as gyms, equip-
ment, and walkable environments. Telehealth PA coaching
may be a promising tool to address disparities in access to
care among those with PD, given that technological barri-
ers are appropriately addressed.70,71 Our group has increased
community-based efforts to ensure inclusion of a more diverse
population in future studies.
Future Directions
Coaching for PA is not currently standard practice in
neurologic physical therapy, and there are many barriers to
implementation in real-world clinical settings. These barri-
ers include the underdevelopment of telehealth infrastructure
(insurance and internet coverage), insufficient training on
coaching for physical therapists and other medical profession-
als, as well as safety concerns. There is growing research
evaluating the implementation of similar coaching programs
for PD,72 but more research is warranted to assess the effec-
tiveness and cost-effectiveness of large-scale implementation
of these programs.
CONCLUSIONS
We demonstrated that a telehealth PA coaching program
delivered by physical therapists for people with PD is feasible
and shows potential benefits in facilitating PA uptake and ex-
ercise self-efficacy. People who have a lower baseline PA level
and ESE may benefit more from a PA coaching intervention.
This demonstrates the promising role of telehealth PA coach-
ing as part of a consultative model of care starting early in the
disease process.
ACKNOWLEDGMENTS
The authors would like to thank the participants for
their time and participation. We also thank Bria Bartsch and
Jehan Alomar for their assistance in this project and neurol-
ogist from the Parkinson’s Disease Center of Excellence at
Columbia University Irving Medical Center for their support.
Finally, we would like to acknowledge the Engage-PD Ad-
visory Group members: Lynn Hagerbrant, Chuck Hendrick,
Holly Fisher, and Saul Zuchman.
248
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JNPT • Volume 46, October 2022
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