Walk with Me Hybrid Virtual/In-Person Walking for Older Adults with Neurodegenerative Disease

Summary

The present protocol aims to inform rehabilitation specialists and fitness instructors in safe, feasible, and evidence-based methods of delivering virtual and in-person walking classes to older adults with neurodegenerative diseases.

Abstract

This study presents a protocol for virtual and in-person walking groups for older adults with neurodegenerative diseases and addresses the decline in physical activity and social connectivity during the pandemic. Physical activity, specifically moderate-intensity walking, has been shown to have multiple health benefits for older adults. This methodology was created during the COVID-19 pandemic, contributing to lower physical activity levels and social isolation in older adults. Both the in-person and virtual classes utilize technology such as fitness tracking apps and video platforms. Data are presented from two groups of older adults with neurodegenerative disease: people with prodromal Alzheimer's disease and people with Parkinson's disease. Participants in the virtual classes were screened for balance impairments before the walk, and any person deemed at risk for falls was not eligible to participate virtually. As COVID vaccines became available and restrictions were lifted, in-person walking groups became feasible. Staff and caregivers were trained in balance management, roles/responsibilities, and delivering walking cues. Both walks, virtual and in-person, consisted of a warm up, a walk, and a cool down, and posture, gait, and safety cues were given throughout. Measures of the rate of perceived exertion (RPE) and heart rate (HR) were taken pre-warm up, post-warm up, and at 15 min, 30 min, and 45 min time points. Participants also used a walking application (app) on their phones to record the distance walked and the number of steps taken. The study showed a positive correlation between HR and RPE in both groups. The participants in the virtual group rated the walking group favorably in terms of improving their quality of life during a period of social isolation and contributing to physical, mental, and emotional well-being. The methodology shows a safe and feasible way to implement virtual and in-person walking groups for older adults with neurological diseases.

Introduction

Older adults with neurodegenerative diseases, specifically Parkinson's disease (PD), have poor mobility, a high risk of falls, decreased quality of life (QOL), and generally decreased activity levels. More specifically, walking difficulties among older adults and people with PD are common, leading to decreased independence and increased morbidity and mortality¹. Age-related changes in gait include altered gait biomechanics, slower gait speeds, and decreased coordination. In PD, bradykinesia and hypokinesia, along with timing and coordination problems, contribute to gait changes².

In addition, older adults have been affected by the onset of the global COVID-19 pandemic in March 2020³. Many countries implemented "isolation and quarantine" and "social distancing" to limit the spread of the virus. Given the high mortality and morbidity rate of older people due to COVID-19, strict social distancing and isolation rules remained in effect for older people for approximately one year until the vaccine became available. Unintended consequences of social distancing and social isolation for older adults include a marked decline in physical activity and a decreased daily step count. For example, many older adults were unable to participate in either daily functional physical activities, such as running errands and social engagements, or formal daily exercise programs for one year or longer. This trend is disconcerting given that many older adults were not achieving the recommended daily amount of physical activity pre-pandemic⁴.

Physical activity participation among older adults and people with PD has been widely researched and has been shown to have physical, psychological, and cognitive benefits for older adults⁵. Improving strength, balance, and endurance can reduce the risk of falls, enhance independence, and improve quality of life. A simple, salient, and low-cost form of exercise is walking. The guidelines for physical activity in older adults suggest 150 min of moderate-intensity exercise, such as brisk walking, per week to obtain health benefits. A heart rate of 64%-76% of the maximum heart rate or a rate of perceived exertion (RPE) between 4 and 6 on the 10-point Borg Rate of Perceived Exertion scale can be used to define moderate walking intensity⁶.

The method presented in this work is a hybrid in-person/virtual walking group format for older adults with and without balance impairment due to neurodegenerative disease. The increased use of online technology-based platforms and the increased technological familiarity among older adults have facilitated the use of this method. The technique was developed during the pandemic, from Summer to Fall of 2020, over several months, and the development process included holding weekly working group meetings of experts to build consensus regarding the methods. These working group meetings preceded the piloting of the method. An advantage of the hybrid method is the ability to involve older adults from distant geographical locations who are at low risk of falls (requiring less supervision) while also supervising those at higher risk of falls or other adverse events. Safety concerns are also addressed extensively in this work.

The purpose of this method is to provide guidelines, recommendations, and procedures to rehabilitation specialists and fitness instructors for the safe and feasible delivery of virtual and in-person walking classes to older adults with neurodegenerative diseases in order to improve older adult physical function and social connectivity and, thus, quality of life.

Protocol

This protocol was approved by the Emory Institutional Review Board and the Atlanta Veterans Administration Research & Development Committee. All participants signed an informed consent document prior to participation.

1. Participant recruitment

1. Recruit older adults and individuals with PD and prodromal Alzheimer's disease (pAD) through flyers, registries, referrals, PD newsletters, educational meetings, webinars, support groups, older adult living communities, and websites (see Table 1 for participant information).
2. Ensure the participants with PD have been diagnosed with "idiopathic" Parkinson's and positively respond to dopaminergic therapy⁷. Ensure that those with pAD have mild cognitive impairment with subjective memory loss.
3. Confirm that participants with either PD or pAD have no other neurological insult and can ambulate 3 meters or more with and without assistance.

2. Safety training

1. Train staff, instructors, care partners, and volunteers through an in-person experiential balance management class, a systematic approach to understanding balance, by presenting information about the three systems underlying balance: vestibular, visual, and somatosensory.
   1. Introduce principles such as the base of support, the center of gravity, and limits of stability. Perform exercises such as (1) standing while shifting to the edges of one's feet and maintaining balance, (2) closing the eyes while standing and shifting weight from foot to foot, (3) observing a partner shift their weight until the partner has to take a step and learning to use body weight to support the weight of a partner.
   2. Use the balance management exercises from the previously mentioned balance management class (step 2.1.1) to increase the team's ability to detect and prevent potential falls in a rehabilitative movement class.
   3. Provide ongoing education to staff given by the principal investigator (PI) and staff physical therapists regarding protecting participants with specific gait and balance impairments.

3. Technological considerations

1. Identify and use any commercially available fitness app (see the Table of Materials) that can track time, distance, steps, pace, elevation, and other parameters needed for goal setting and to show progress.
2. Identify a team meeting platform with video and sound capabilities (see the Table of Materials) for the virtual warm up.
3. Use a one-tap mobile or conference call line for the virtual walk and cool down.
4. Utilize heart rate monitors (see the Table of Materials) to track the heart rate throughout the walk.
5. Create detailed written and picture instructions for using the fitness app, video team meeting platform, and conference call line. Email the instructions to all new participants 2 days prior to the walk day. Give technical support to all participants prior to and throughout the walks.

4. Overground walk environment

1. Plan and inspect a safe outdoor walking route in terms of the convenience, safety, and appropriateness for older adults with sensory and motor impairments prior to the in-person walk in the local neighborhood, town, or near the older adult center.
   1. Make a note of rest spots, benches, and shade, which can be useful during the walk, any uneven surfaces and curbs, which may present safety issues, and other important environmental assets or hazards. Consider the amount of traffic in the area and the overall quality of the sidewalks and/or walking paths.
2. Ensure that there is an appropriate, older adult-safe walking environment, including limited traffic, clear and even sidewalks, benches or other rest spots, shade, and mostly level ground. Some small inclines and declines may be tolerable, but check for ramps for those participants using rolling walkers.

5. Participant screening for virtual versus in-person walking groups

1. Request that the participants complete a questionnaire regarding their age, education, medical history, fall history, use of assistive devices such as canes/walkers, and current medications during their initial testing session or prior to the first walk. Review the form with all the participants to ensure completeness/accuracy.
   NOTE: Participants are not deemed appropriate for virtual walking classes due to safety considerations if they have a score of 4 or higher or if they answer "yes" to any of the first three key questions on the Stay Independent Screener⁸, if the participant scores a 2 or higher on item 3 of the New Freezing of Gait Questionnaire⁹, if an assistive device is used regularly, or if the participant reports falling more than once per month.
2. Use other fitness metrics to assess the fitness to maintain safety and to evaluate progress (e.g., heart rate monitoring, VO₂ submaximal assessment, 6 min walk test, Mini Best test, and vascular function measurement using a commercially available device)^10,11,12 (see the Table of Materials).

6. Schedule the participants for a walk

1. Host virtual and in-person walks simultaneously with the number of staff necessary to fill the lead, co-lead, and back-marker positions, as well as any other staff needed for safety/assistance.
2. Schedule the walks at a time of day that is appropriate for the group.
3. Schedule the walks twice per week for 12 weeks, ensuring a minimum of 20 walks in total. After 12 weeks, invite the participants to walk once per week. The walk presented in this study was 90 min, including the warm up, walk, and cool down.
4. Email the virtual walk group instructions to participants 2 days prior to the day of the walk. The instructions are below:
   1. Use an invitation with a link to a one-tap mobile or other video or conference call line.
   2. Provide new participants with instructions on how to use the technology and fitness tracking app, as well as regarding safety and appropriate attire.

7. Staff roles and responsibilities

1. Group lead responsibilities
   1. Identify participants who have similar walking abilities before the walk. Assign back-markers/staff to participants who are deemed a high fall risk to protect them during the warm up, walk, and cool down.
   2. Introduce the self and the co-leader at the beginning of the session, along with other staff members. Educate the participants on the Borg Rate of Perceived Exertion (RPE) 10-point scale¹³, which is used to determine the participant's perceptions of their physical effort. Briefly discuss the session's agenda.
   3. Lead a total body warm up using cues for safety, effort, and time/repetitions.
   4. Monitor the remote participants during the warm up to ensure proper form, alignment, and safety.
   5. Motivate the participants. Tell them they are doing well if they participate. Congratulate all the participants on their efforts.
   6. Pay attention to the time for the warm ups, breaks, walks, and cool downs.
   7. Assess the participants continuously during one-tap mobile/conference call during the walk for safety, intensity, and form.
   8. Provide verbal cues for posture and gait mechanics (Table 2) after each RPE update and if a participant has not been heard speaking for a long period of time (to ensure we do not lose contact with a participant).
   9. Encourage rest and hydration breaks.
   10. Ask the participants about their walking environment (e.g., sidewalks, hills, etc.) and their walking form (posture). Check in with the participants frequently about safety concerns and how they can monitor and maintain good biomechanics of gait.
   11. Lead the cool-down after the walk on the one-tap mobile or conference call line.
   12. Answer any questions regarding the technology, walking form, intensity, goals, etc.
   13. Take over responsibilities if the co-leader becomes disconnected for any reason.
2. Co-lead responsibilities
   1. Email the participant information and instructions for the fitness tracking app and team meeting links to all the participants 2 days prior to the walk.
   2. Take attendance at the start of the meeting. If a participant is not in attendance, call the participant to check on them.
   3. Assist the participants with the use of technology during the practice team meeting video calls.
   4. Assist the participants during the transition between the video call and the one-tap mobile call during the 5 min break.
   5. Assist the participants with the setting up, usage, and starting/stopping of the fitness tracking app.
   6. Ask and record the participants' RPE and heart rates pre-warm up, post-warm up, and at the 15 min, 30 min, and 45 min time points of the walk.
   7. Manually record the RPE, heart rates, steps, distance walked, elevation, and average pace for the participants at the 45 min time point of the walk.
   8. Enter the data into any commercially available database survey software immediately or as soon as possible after collecting the data.
   9. Take over group leader responsibilities should the group leader become disconnected from the call for any reason.
3. Back-marker/other staff responsibilities
   1. Ensure all the participants' safety, particularly for the participants who have slower walking speeds, use an assistive device, or have a heightened fall risk, postural instability, or freezing of gait. Staff may be paired one-on-one or even two-on-one with participants who have been deemed a high fall risk.
   2. Ensure participants are walking along the same route and no participants become lost on the route. Watch for traffic carefully, and alert the group to oncoming traffic.
   3. Assist with any additional responsibilities as requested by the group leader or co-leader.
   4. Socialize with the participants during the walk.

8. Virtual and in-person walk: Preparation steps

1. Virtual walk procedure
   1. At 15-20 min prior to the class time, log into the video team meeting. Educate new participants on the RPE scale. Lead a warm up for 25 min. Take the RPE pre- and post-warm up (co-leader).
   2. The warm up is performed by the group leader with whole-body large-amplitude movements incorporating posture, weight shifting, rotation, and stepping. Lead the warm up in both seated and standing positions with cues for safety, effort, amplitude, and form. Verbally ensure the safety of the participants.
   3. Implement a break for 5 min to prepare the participants for the walk. Assist the participants in logging on to the approved fitness tracking app and one-tap mobile or other conference call line.
   4. Instruct the participants in proper posture and gait mechanics after every RPE check-in and through the walk. See Table 2 for a complete list of cues. Ask the participants to be mindful of their environments and to describe their surroundings.
   5. Limit the walking group to four to six participants. Strongly encourage the participants to bring a caregiver or a walking buddy to their walks. Discuss with the participants the location and terrain of the walks prior to the first walk to ensure safety and familiarity with the chosen area.
   6. Take and record the participant's RPE at 15 min, 30 min, and 45 min.
   7. Ask the participants to stop their fitness tracking app after 45 min and participate in a 5-10 min guided cool down from the instructor delivered through the audio function.
2. In-person walk procedure
   1. Arrive at an established walking location wearing a mask. Screen the participants for COVID-19, and assist with wearable HR and fitness tracking technology. Educate new participants on the RPE scale and agenda.
   2. Lead a warm up with whole-body large-amplitude movements incorporating posture, weight shifting, rotation, and stepping. Lead both seated and standing exercises with cues for safety, effort, amplitude, and form. Have an assigned staff member protect the participants with balance impairments to ensure their safety.
   3. Record the RPE and HR pre- and post-warm up.
   4. Implement a break for 5 min to prepare the participants for the walk. Assist the participants in starting the walking app technology.
   5. Divide the walking group into smaller groups based on speed, ability, and fall risk. Assign each walking group a leader, a back-marker, and/or other study staff, with one person in each group remaining on the audio call. The leader of the group with the greatest walking mobility leads the virtual walking group.
   6. Record the RPE and HR at the 15 min, 30 min, and 45 min time points.
   7. Give posture and gait cues at the beginning of the walk at 15 min, 30 min, and 45 min. Safety is of the utmost importance. Participants who are considered a high fall risk will have at least one person walking with them for safety and guarding. These individuals should be closely monitored for fatigue. Give cues for environmental hazards and encourage rest breaks and the use of assistive devices.
   8. Ask the participants to stop their walking app at the 45 min time point and participate in a 5-10 min guided cool down.
   9. Administer a satisfaction questionnaire intermittently (approximately every 10 classes) to determine the level of enjoyment the participants are experiencing.

9. Participant post-evaluation

1. Measure the chosen fitness metrics, as noted in step 5.2, to determine the change in the participants' fitness over the course of the walking program.
2. Administer a participant satisfaction survey.

Results

Pilot virtual walking group
During COVID-19, an expert working group of seven individuals created and implemented the virtual walking protocol with eight pilot participants. The working group consisted of a PI, a physical therapist, an exercise physiologist, a lab manager, two research study coordinators, and a graduate student. The working group met virtually every week to form a consensus on the methods preceding the pilot of the methods. To pilot the methods, participants from the PD and older adu...

Discussion

The methods detailed above describe a safe and feasible way to implement a low-cost, salient, over-ground walking program for older adults with neurodegenerative diseases^1,2. The virtual classes were shown to be effective in contributing to physical and mental well-being and quality of life during a period of social isolation due to COVID-19³. Once the quarantine measures were lifted and COVID-19 vaccines became readily available, the part...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Chest strap heart rate monitor	Polar	NA
Computer with video/sound		NA
Fitness tracking app	Any commercially available app	NA
iPAD	Apple IPAD	NA
Pressure management device	Atcor Medical, Australia	SphygmoCor
Smartphone	Apple or Android	NA
Standard chair		NA
Team meeting platform	Zoom	NA