A total of 35 individuals were contacted to enrol in the study (25 physiotherapists and 10 PwPD), of which 28 were included after accepting the invitation and being screened for eligibility. The sample comprised 20 physiotherapists (mean age 34.50 ± 10.47 years; 12 male) and 8 PwPD (mean age 65.75 ± 8.63 years; mean H&Y 2.0 ± 0.76; 5 male). Further details about the characteristics of the participants are provided in Tables 2 to 5.
Table 2 - Characteristics of the sample included in the study
N Age Age range Gender
Mean (SD) Min – Max Male (%)
Participants (total) 28 43.43 (17.41) 23 – 75 17 (60.7%)
Physiotherapists 20 34.50 (10.47) 23 – 60 12 (60%)
PwPD 8 65.75 (8.63) 49 – 75 5 (62.5%)
Table 3 - Socio-demographic characteristics of physiotherapists displayed as mean ± SD (%)
Physiotherapists (n=20)
Educational Background
Bachelor’s (Hons) Degree: 11 (55%)
Post-graduation: 6 (30%) Masters: 2 (10%)
PhD: 1 (5%) Professional Setting
Private: 13 (65%) Public: 6 (30%) Both: 1 (5%)
Years of clinical practise 10.74 ± 9.17 (1.5 to 38) Year of experience in Neurology 9.84 ± 9.30 (0.5 to 38) Number of PwPD currently treating 1.2 ± 1.08 (0 to 3)
Within the 19 physiotherapists currently working with patients, 11 (57.89%) reported prescribing exercise frequently, 5 (26.32%) occasionally and 3 (15.79%) rarely. For PwPD, 10 (52.63%) prescribe exercise frequently, 2 (10.53%) occasionally, 6 (3158%) rarely and 1 (5.26%) never prescribes exercise for PwPD. Further details are outlined in Table 4.
Table 4 - Characterization of the physiotherapists concerning their habits of exercise prescription and use of software for such purpose
Exercise Prescription Exercise Prescription for PwPD
Use of software for exercise prescription
Frequency n % n % n %
Never 0 0 1 5.26 2 10.53
Rarely 3 15.79 6 31.58 7 36.84
Occasionally 5 26.32 2 10.53 8 42.11
Frequently 11 57.89 10 52.63 2 10.53
Always 0 0 0 0 0 0.00
Total 19 100 19 100 19 100
Table 5 - Socio-demographic characteristics of PwPD displayed as mean ± SD (%)
PwPD (n = 8)
Time since diagnosis (years) 11.63 ± 6.80 (0 to 21) Hoehn and Yahr score
2.0 ± 0.76 (1 to 3) Stage 1: 2 (25%) Stage 2: 4 (50%) Stage 3: 2 (25%) Educational background
5 to 9 years of school: 3 (37.5%) 10 to 12 years of school: 4 (50%) University education: 1 (12.5%) Professional status Retired: 7 (87.5%)
Employed: 1 (12.5%) Physiotherapy attendance Yes: 7 (87.5%)
No: 1 (12.5%) Physiotherapy weekly frequency Twice: 3 (43%)
Three times: 4 (57%) Physical exercise habits
Exercise outside the clinical setting Yes: 5 (62.5%) No: 3 (37.5%) Exercise weekly frequency
Once: 1 (20%) Twice: 1 (20%) Three times: 1 (20%) Five times: 2 (40%)
Exercise modes Walking: 3 (33.3%)
Table Tennis: 2 (22.2%) Handball: 1 (11.1%) Swimming: 1 (11.1%) Cycling: 1 (11.1%) Use of technology
Technological devices
Smartphone: 6 (75%) Tablet: 1 (12.5%) Computer: 5 (62.5%) Use of the functionalities of the
devices
Phone calls: 8 (100%) Text messages: 7 (87.5%) Take pictures: 4 (50%) Record videos: 4 (50%)
Browse the internet: 5 (62.5%) Barriers for using the devices Lack of touch precision using
touchscreen devices: 1 (12.5%) Regular internet usage Yes: 7 (87.5%)
No: 1 (12.5%)
The first section of the questionnaire to gather feedback on the Mobile App comprised the recognition of the barriers perceived by each participant regarding their own exercise practice. Of the three participants that reported not exercising, one does not exercise due to lower limb muscle fatigue, and another prefers more sedentary activities like browsing the internet. The other participant discontinued exercise due to the closing of the facilities where their exercise classes took place, since March 2020, upon to the lockdown following the COVID-19 pandemic. The following section of the questionnaire assessed previous experience with similar mobile apps as to the one being demonstrated. Six participants (75%) reported never having used similar apps. One participant referred having used an app to support exercise practise, and another had already provided feedback on the first prototype of the ONParkinson mobile app.
Usability of the Web Platform
After testing the Web Platform, physiotherapists awarded SUS a final mean score of 79.50 points (outlined in red in Fig. 4) ± 12.40, ranging from 55 to 95 (outlined in blue in Fig.4).
The mean score can be considered a "Good" usability score, corresponding to the transition
between a C and B grade (Bangor et al., 2009). It can also be considered an A- grade since it falls into the 85th to 89th percentile range when compared to other studies (Lewis, 2018).
Considering the sample of 20 participants, the confidence interval (CI) for average SUS score was calculated using Student’s T distribution for a 95% confidence level. Its lower and upper bounds were 73.70 and 85.30, respectively (outlined in green in Fig. 4). The lower bound of the CI can be considered a “Good” score and a C grade (Bangor et al., 2009), or a B-, within 65th to 69th percentile (Lewis, 2018). At the upper bound, it can be considered an “Excellent”
score and a B grade (Bangor et al., 2009), or an A+, within 96th to 100th percentile (Lewis, 2018).
Figure 4 - SUS scores attributed by participants, framed within the classification of Grade (Lewis, 2018), Acceptable and Adjective (Bangor et al., 2009). Legend: mean score (red), range (blue), upper and lower bound of the confidence interval (green); NPS: Net Promoter Score
The SUS individual answers were analysed as a 5-point Likert scale based on strength of agreement, with answer options ranging from 1 to 5. The mean score for the positive questions (1, 3, 5, 7 and 9) was 4.13 ± 0.76, ranging from 3.95 to 4.30. The mean score for the negative questions (2, 4, 6, 8 and 10) was 2.16 ± 0.87, ranging from 1.50 to 2.30. A heatmap (Table 6) was used to provide a visual interpretation of this answers, by facilitating the recognition of functionalities that work as intended and the ones that need to be improved. Results suggest that participants would like to use the platform frequently, it has few inconsistencies, it is relatively easy to use and they did not have to learn much to use it. However, they have considered the
platform unnecessarily complex, have not felt very confident using it and some believe that they would need technical support to be able to use it.
Table 6 – SUS scores displayed per question (mean and SD); mean scores of positive questions highlighted in green and of negative questions in red. Heatmap for individual answers.
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 Mean SD
Q1 4 4 3 5 5 4 5 4 4 4 4 5 4 4 5 4 5 5 4 4 4.30 0.57
Q2 4 3 3 2 3 1 1 1 1 1 3 2 4 1 2 2 4 2 2 4 2.30 1.13
Q3 2 4 3 4 4 5 5 3 5 4 3 4 4 5 5 5 4 4 5 4 4.10 0.85
Q4 1 1 4 2 2 2 1 3 1 2 1 3 4 1 1 1 1 3 1 2 1.85 1.04
Q5 5 3 4 5 3 4 5 5 4 4 3 4 5 4 4 4 5 5 5 3 4.20 0.77
Q6 2 1 3 1 2 1 1 1 1 1 2 1 2 2 2 2 1 1 2 1 1.50 0.61
Q7 3 5 4 5 4 4 4 3 4 4 3 4 3 5 5 4 5 5 5 3 4.10 0.79
Q8 3 1 3 1 1 1 1 2 1 2 2 1 3 1 1 1 1 1 1 3 1.55 0.83
Q9 2 4 4 4 5 3 4 3 5 4 3 4 3 4 5 4 5 4 5 4 3.95 0.83
Q10 3 1 3 2 2 2 1 2 1 1 1 2 2 1 1 1 1 1 3 2 1.65 0.75
Assessment of the Mobile App
The evaluation of the CA integrated in the Mobile App comprised 12 questions which answers consisted of a 5-point Likert scale based on strength of agreement, with answer options ranging from 1 to 5. The mean score for the 12 questions was 4.42 ± 0.79, ranging from 4.13 to 4.75. The mean score per participant was 4.44 ± 0.45, ranging from 3.58 to 5.00. The content of the questions and details regarding the mean score and standard deviation for every question is provided on Table 7. A heatmap (Table 7) was used to provide a visual interpretation of this answers, by facilitating the recognition of functionalities that work as intended and the ones that need to be improved. Regarding the domain of user experience, results suggest that that PwPD were able to ask the CA for guidance and understood its voice and the answers provided. It also aided while participants navigated through the exercise program, answering correctly about the current training phase, the exercise commands, and the number of sets and repetitions of the exercise. Nevertheless, voice and text recognition must be improved, and PwPD reported the need for a better understanding on what type of questions the CA is prepared to answer, given its body of knowledge.
Table 7 – Scores displayed per participant and per question (mean and SD). Heatmap representing the answers regarding the evaluation of the CA. Legend: Q (Question); P (Participant). Observation: the 2nd and 3rd answers provided by P7 were not considered for data analysis since the test conditions did not allow for the listening component to be performed.
P1 P2 P3 P4 P5 P6 P7 P8 Mean (Q) SD (Q) Q1. Fui capaz de pedir ajuda 5 4 5 4 5 5 5 5 4.75 0.46 Q2. Reconhece a minha voz. 5 3 4 4 4 4 5 4.14 0.69 Q3. Entendo a sua voz 5 3 5 4 5 5 5 4.57 0.79 Q4. Reconhece o que escrevo. 3 4 5 3 5 5 5 5 4.38 0.92 Q5. Entendo as respostas que me dá 5 4 5 4 5 5 5 3 4.50 0.76 Q6. Entendo o que posso perguntar 5 4 5 4 5 4 5 1 4.13 1.36 Q7. Reconhece o que selecionei 5 3 5 4 5 4 5 5 4.50 0.76 Q8. Esclareceu as minhas dúvidas 5 4 5 4 5 4 5 1 4.13 1.36 Q9. Ajudou-me a entender a fase de treino 5 4 5 4 5 4 5 5 4.63 0.52 Q10. Fui capaz de continuar o programa 5 3 5 4 5 4 5 4 4.38 0.74 Q11. Ajudou-me a saltar de exercício 5 3 5 4 5 4 5 4 4.38 0.74 Q12. Entendeu quando não me sentia bem 5 4 4 4 5 5 5 5 4.63 0.52
Mean (individual participant) 4.83 3.58 4.83 3.92 4.92 4.42 5.00 4.00 SD (individual participant) 0.58 0.51 0.39 0.29 0.29 0.51 0.00 1.54
Furthermore, when asked about their preferences regarding the options for the input of biometric data (heart rate and blood pressure), five participants (62.5%) preferred the scroll feature, while the other three (37.5%) preferred inserting the algorisms on the keyboard.
Insights from the perspective of physiotherapists and PwPD
The initial deductive approach to thematic analysis resulted in the development of a codebook (Appendix 12), based on the features of the Web Platform and the Mobile App and the question guides of the semi-structured interviews. An individual description of themes and sub-themes is provided in the codebook. After clustering the within each theme or sub-theme, a traffic light colour coding was used for each code to assist in visual interpretation, where green, yellow, and red corresponded to positive feedback, negative feedback, and recommendations for improvement. This approach intended to further complement and elaborate on the results obtained from SUS and the questionnaire to assess the CA, thus promoting integration at this stage. The section of the codebook directed to the Web Platform comprised six initial themes:
Web Platform, Exercise Database, Exercises Tab, Programs Tab, Patients Tab, and PD Management. The section directed to the Mobile App comprised five themes: perceived benefits, disadvantages, recommendations for improvement, suitability for PwPD and the user interface of the app. The process of reviewing and refining themes using an inductive approach was based on the initial codebook and has resulted in a thematic map comprising three themes, each containing two to three sub-themes, further described in Table 8.
Table 8 - Thematic Map derived from an inductive approach
Theme Sub-theme Description of sub-theme Perceived role of
the ONParkinson digital solution
Highlighted
functionalities/ features of the Web Platform
Perceived benefits of the Web Platform and its potential role on exercise prescription for PwPD
Role of the Mobile App on promoting
self-management and patients’
autonomy
Perceived role of the Mobile App on promoting self-management skills and autonomy of PWPD, as well as potentially enhancing long-term exercise adherence Facilitators and
barriers for engagement with the ONParkinson digital solution
Facilitators for engagement with the ONParkinson digital solution
Perceived facilitators by physiotherapists and PwPD for engagement with the components of the digital solution (Web and Mobile)
Barriers for engagement with the ONParkinson digital solution
Perceived barriers by physiotherapists and PwPD for engagement with the components of the digital solution (Web and Mobile)
Recommendations to improve the usability of the ONParkinson digital solution
Main features and design of the Web Platform
Recommendations for improving the usability of the Web Platform regarding its design (writing fields, lists of exercises and programs, parameters for exercise prescription) and main features (adding and associating exercises programs, section of clinical records and personal data)
Main features of the Mobile App
Recommendations for improving the functionalities of the Mobile App
Database of exercises
Recommendations for expanding the database of exercises, while considering the suitability and safety of the exercises
Perceived role of the ONParkinson digital solution
Highlighted functionalities/ features of the Web Platform
Physiotherapists have considered the Web Platform a valuable resource for exercise prescription for PwPD, due to its efficiency on creating individual exercises and exercise programs and being able to assign those to their patients. They have acknowledged its potential role for telerehabilitation, as well as to increase awareness for the growing evidence supporting exercise prescription for patients with neurological conditions. Positive remarks were reported regarding the feature that enables physiotherapists to modify exercise programs based on real-time patient feedback; it was considered distinct among exercise prescription platforms, due to its relevance on enhancing PD management through a single technological resource.
“There are some platforms designed towards creating exercises and sending those to patients, but this one allows to modify programs based on real-time patient feedback, and to verify whether the patient has attained the aims for any exercise program. These features are much more significant than the ones provided by the remaining platforms”. (Physiotherapist 12)
Role of the Mobile App on promoting self-management and patient autonomy The role of the mobile app on PD management was particularly addressed on the semi-structured interviews and was considered by both physiotherapists and PwPD as an invaluable resource to promote self-management. It was also found to be advantageous on promoting digital health literacy, and to address barriers that may hinder disease management, such as the lack of accessibility to rehabilitation settings along with the financial burden, and personal beliefs regarding the unawareness of the relevance of exercise engagement on PD.
Physiotherapists have highlighted the role of the app on empowering the dyad to exercise outside of the clinical setting, without direct supervision, thus promoting accountability and autonomy. Being capable of using the app can potentially enhance exercise related self-efficacy, which can further increase motivation and long-term adherence. The resulting increase of exercise and physical activity levels can subsequently reduce the burden of comorbidities related to physical inactivity on both PwPD and their caregivers.
“If (the patient) can do (the exercise program) on his own, and even come up with questions, somehow feeling in control of their training, it addresses patient autonomy, not only regarding motor performance, but also at the psychological and cognitive levels, which is very significant. Self-management? Yes, without a doubt. Additionally, if (the patient) succeeds at the activity that is being undertaken, amazing.” (Physiotherapist 11)
“Increasing physical activity levels, self-management skills regarding physical activity and PD symptoms, empowers the patient.” (Physiotherapist 3)
PwPD have placed high expectations on the potential role of the app on PD management.
They have considered it as a suitable resource for promoting exercise practise, while indirectly being supervised by their physiotherapist, thus increasing motivation to exercise. Three participants reported they would be interested in using the app when available.
“One becomes more autonomous and may be able to obtain results by himself. At least (the patient) is being provided the tool to achieve such aim.” (PwPD 2)
“I liked (the Mobile App) and exercising with company or supervision is always more motivating.” (PwPD 7)
Facilitators and barriers for engagement with the ONParkinson digital solution Facilitators for engagement with the ONParkinson digital solution
Facilitators for engagement with the Web Platform by the physiotherapists comprise the possibility to customize exercises and programs, and a visually appealing, minimalistic and intuitive design providing greater efficiency.
Facilitators for engagement with the Mobile App were categorized within three main subjects: characteristics of PwPD, social support, and features of the mobile app.
Physiotherapists pointed out that adherence may be more related to intrinsic traits of PwPD rather than the app itself, and their beliefs on the role of exercise on PD management.
Nevertheless, those with a greater degree of independence may me more prone to adhere to the app. There is also the chance of not being able to get more patients to exercise through the app, but instead to facilitate exercise practise for those who already engage in it. Regarding social support, the feature that will enable contacting the physiotherapist through the app has been
considered beneficial for sustained adherence. Caregivers also seem to play a fundamental role on adherence by directly facilitating the access to the app if the patient is unable to manage it, and/or providing support and motivation while the patient is exercising.
“(Adherence) will indeed depend on the profile of the patient, the support provided by their family and their own beliefs regarding the role of rehabilitation.” (Physiotherapist 2)
“Guidance and follow up are provided (to the patient) by the health professional, who will recommend an exercise-based intervention based on previously identified goals. I believe that patients might adhere to it.” (Physiotherapist 19)
Regarding the Mobile App, the description for each exercise was found to be well explained, being subdivided in starting position, instructions, breathing and safety concerns.
Exercise videos were considered advantageous on providing visual feedback, and its audio description was understandable, although playback speed could potentially be too fast considering the impairments of some PwPD. However, the language used in the descriptions and the addition of visual cues was considered beneficial. Participants highlighted the importance of having exercise commands concise and easy to understand, so that it will not hinder motivation of PwPD to follow the programs. Also, naming the same exercise differently, directed to the physiotherapists, and the less technical name for PwPD, has been considered advantageous since it is more relatable to them.
PwPD found the instructions and commands easy to understand and follow, and the feature of the CA that reads the text aloud was helpful for navigating the app. The app comprises the essential information to engage in exercise practise, without overloading the user. Frequent and continuous use could facilitate user interaction, as well as previous knowledge of the existing exercises, since following the program becomes more intuitive.
“The exercise descriptions (in the App Mobile) were detailed enough to understand the instructions. I have known those exercises (demonstrated during the test) for a very long time.
While it may pose as a novelty for beginners, they will be able to follow along when regularly using the app.” (PwPD 1)
Barriers for engagement with the ONParkinson digital solution
Nonadherence to the web platform can be determined by the policies of rehabilitation settings and other external factors. Nevertheless, few information on how to operate the platform and too much complexity given its intended purpose can hinder adherence. There is also an initial time investment since physiotherapists must get familiar with an extensive exercise database, which can be considered time consuming and subsequently decrease adherence.
“In order for me to be able to use the website, I have to know what is on it (…) Imagine the time I would have to lose, in quotes, invest, but at the same time lose, reviewing every uploaded exercise, and that can cause some distancing.” (Physiotherapist 2)
Regarding barriers for engagement with the Mobile App, physiotherapists have identified a low degree of digital health literacy, and pathophysiological changes due to disease progression affecting motivation and subsequently adherence. On the other hand, may not want to exercise at all, regardless of the app, and some may prefer exercising in a clinical setting. The latest is related to the potential detrimental influence of the absence of the physiotherapist during exercise training since they would not be able to provide real-time performance feedback.
PwPD have not identified any barriers towards using the app, although one of the participants had concerns on its cost upon public released and mentioned he would only adhere if it was available as a free resource.
“I believe the only disadvantage relies on the capacity for using digital health resources (…) there will have to be a timeframe for adaptation and training with the physiotherapist to understand their difficulties.” (Physiotherapist 20)
Recommendations to improve the usability of the ONParkinson digital solution Main features and design of the Web Platform
The exercise programs added to the Web Platform contain one major exercise type (strength, balance, aerobic or ADLs). One of the main disadvantages pointed out is the lack of hybrid exercise programs, considering preference of PwPD and symptom management.
Individualized video tutorials were also recommended for each section of the platform; an introductory video should only contain an overview of its purpose and main features. A feature
for enabling to export and print exercise programs was suggested, considering some patients may not be able to access the mobile app or prefer having the program on a handout. The most prevalent recommendation regarding the design of the Web Platform was to add a colour scheme since the current version is based on a grey scale. Some technical aspects have also been mentioned, such as to avoid lateral scrolling in pop-up windows.
“When thinking about several patients of mine, it makes more sense when (exercise types) can be combined (in the same exercise program), and I believe it is more enjoyable for patients when they are exercising. It does not make sense (not having hybrid programs) since we may not only work one component. For instance, considering a patient with greater fatigue, it would make more sense for the exercise program to comprise several exercise types to avoid fatiguing specific muscle groups or energy systems. I believe this may be a gap.”
(Physiotherapist 10)
Physiotherapists have also provided feedback on features of the Web Platform, within the three pre-existing tabs (Exercises, Programs, Patients).
The search filters for displaying the list of exercises are yet to be developed. Thus, recommendations included adding pictures to easily identify the exercises, and to either provide search filters or display the exercises trough a drop-down menu, divided by exercise types and subtypes, since finding the desired exercise with the current display is time consuming.
“In order to know the exercises from the database, I must open the exercise details and watch the video, and that consumes a lot of time. If I had some guidance, and an image associated with a video, then exercise selection would be facilitated. Additionally, with filters, I could select the presence of the caregiver, the training phase and the required equipment that the patient may have available.” (Physiotherapist 19)
The features of adding a new exercise or a new program comprised text fields, which were considered unclear since physiotherapists had difficulty understanding what they should write in each one. Thus, having a placeholder text within the text boxes and adding informative notes was recommended. There should also be a clear distinction between adding a new exercise and copying a pre-existing template exercise. All the text fields must be written using
Markdown, a markup language for creating formatted text using a plain-text editor, so that the text on mobile app can integrate formatted instead of only plain text. Nevertheless, physiotherapists found this type of writing attainable if there are guidelines available.
The process of adding an exercise program was considered time consuming, and only being able to see the name of the exercise (and not its details) at this stage was considered a limitation. On the other hand, not being able to see the details of the program other than when creating it was considered a drawback, since such information should always be available within the list of programs. Further recommendations consist of applying filters when choosing the exercises to add, changing exercise order once selected, being provided several checkboxes with equipment options instead writing it out and editing pre-existing programs (as it is possible with exercises). Exercise prescription is included in the feature of adding a new program.
Physiotherapists found it to be efficient when prescription parameters from previous exercises are passed on to the next ones, thus sparing time if they wish to maintain the same parameters.
Further recommendations include being able to select every exercise for the program, and only then moving to the prescription.
“When we lose time searching (for the intended exercises) we eventually find it may not be that user friendly.” (Physiotherapist 2)
Although associating an exercise program to a patient was considered intuitive, adding a calendar as a way of providing visual feedback of the days that the patient is supposed to complete the program could be beneficial, as well as prescribing according to weekly frequency instead of specific days, letting the patient decide which days are more suitable to exercise. As to personal data of PwPD, identifying patients by name and gender was considered intuitive.
Recommendations comprised adding date of birth as an identifier, and to register the on/off periods of PwPD, as to consider timing for exercise prescription.
Main features of the Mobile App
The password that provides access to the mobile app, generated on the web platform, was found to be too complex. Four to six characters, preferably numbers, were recommended.
Recommendations towards improving the Mobile App include providing exercise reminders,