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4D: Deep Dive into Degenerative Diseases - ANPT
DD SIG Bonus Episode: CSM 2026 Poster Award: Telerehabilitation and Parkinson’s Disease with Paria Darbandsari
00:31:45
In this episode, host Ken Vinacco is joined by CSM 2026 DD SIG Poster Award winner Paria Darbandsari. They discuss her study on the effects of telerehabilitation on Parkinson’s Disease including what telerehabilitation methods have been studied,
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- [00:02]
A
Welcome to 4D deep dive into Degenerative Diseases, Gaining insights through casual and amusing clinical conversations welcome to 4D podcast brought to you by the Degenerative Diseases Special Interest Group of the Academy of Neurologic Physical Therapy. A component of appa. This is for informational and educational purposes only. It should not be used as a substitute for clinical decision making. The Academy of Neurologic Physical Therapy and its collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. The views or opinions expressed are those of the individual creators and do not necessarily represent the position of the Academy of Neurologic Physical Therapy. I'm Ken Vanako, a physical therapist in the Outpatient Neuro Clinic at Brown University Health and on the Podcast Committee of the DD Sigma. I'm excited to be here with Pariah Darbhansari, who is a PhD student at the University of Connecticut. Paria, thank you for coming on. Please tell us a little bit more about yourself and your role at UConn.
- [01:09]
B
I'm Pariya Darbhansari. I'm a second year PhD student and a Physical therapist at Kinesiology Department, University of Connecticut and a Research Assistant in Movement for Life Lab again at the University of Canada. Cat. I want to take a moment to thank the Generative Disease Special Interest Group for this award and for giving me this opportunity to just talk about my research. Thank you.
- [01:33]
A
Absolutely, absolutely. And I should start with saying that you did win the award for Best Poster through the Degenerative Diseases Special Interest Group and that poster's title was the Effect of Telerehabilitation and Parkinson Disease A Systematic Review and Meta Analysis.
- [01:52]
B
Yes, yes, right.
- [01:55]
A
Could you tell us a little bit more about what was the inspiration for this project for this poster?
- [02:02]
B
Yes, right, of course. So I got my physical therapy degree in 2019 and then I worked as a clinician for three years and after that I decided I wanted to do a Master's. So I came to UConn, I did my Master's and this project was my Master's thesis and then I continued as a PhD here. So I was a full time clinician when the COVID happened and firsthand I could see the effects of COVID and how the interrupted sessions and the uncertainty of being able to continue a rehabilitation session with our participants was affecting them and was also affecting me as a physical therapist in like how I could better support them.
- [02:44]
A
Right.
- [02:45]
B
Unfortunately, when I was in the clinic we didn't have the resources or the opportunity to provide tele rehabilitation so it was just also adding another layer of like, back of my mind, I was just thinking how important it can be to during hard times like Covid, to provide that same amount of support and care. So moving forward, coming here, I took a course in my first years of masters. It was related to systematic review and how to do a systematic review. So I chose the topic of telehabilitation and I did the search and it kind of just started. Everything is stemmed from that course. I moved forward with the question. The question got bigger and it changed as it was becoming my master's thesis. But it was just the idea of like providing care when there is a limitation and barrier in coming to in person settings. So that was like where it all started.
- [03:39]
A
Yeah, well, it's definitely a great origin of this project. And it was so true. Right. And we were kind of all new to Telerehab and using Zoom as Covid kind of hit us and definitely adapted over the years and maybe provided more of an opportunity for us to address some of these barriers. Right?
- [04:00]
B
Yeah, yes, of course. Exactly right.
- [04:03]
A
And this recently was published in ptj. Did I see that?
- [04:07]
B
Yes, this was recently published and it was just another thing to celebrate. So I'm so happy and honored to publish in ptj.
- [04:15]
A
Yeah, very cool. Very cool. So within Telerehab, you mentioned that there are some potential barriers that are addressed. What are some of those barriers that you found in your systematic review that Telerehab does address?
- [04:31]
B
So the whole question was that there is no doubt that the regular engagement in physical activity and physical therapy is such a core component of disease management when it comes to Parkinson's disease. And the idea was that, so there are barriers. Like in my practice, I've had patients that were facing transportation barriers or like weather was unreliable and it was changing and they couldn't come because of the snow or because of like other conditions. And there was limited access to care or limited access to quality care, or maybe could be severe conditions and like progressed disease conditions and motor symptoms that was just making hard to continue with the regular participation engagement in rehab sessions and like physical therapy in general. So the question was that now we have telerehabilitation. Could telerehabilitation be something that we could rely on and help us get the same outcome measures, the same quality? So the whole idea was to look at the effect of telerhabitation in our patient population. But then the outcome measures was kind of designed in a way through the International Classification of Function and Disability to help us better understand how telo rehabilitation is affecting our patients as a whole, how it's affecting their body function and structure, how it's affecting their activities, but also how it's affecting their participation, quality of life and social support. So we wanted to see how tele rehabilitation is affecting this population as a whole and not just to take like motor outcome measures and just make a decision based on that. We wanted to be as holistic as we could.
- [06:12]
A
Absolutely. I think the choice to separate these outcomes using the ICF model helps to capture that whole picture. Can you tell us a little bit more about what were the outcome measures that you were looking at and trying to figure out the effects of Telerehab?
- [06:29]
B
Yes, we looked at four different domains of icf. We looked at body function and structure and we had balanced under that. We looked at balance, confidence and control of balance. In the activities domain, we had gait, we looked at gait endurance outcome measures, gait speed and gait biomechanics. We had physical activity and functional mobility. And then under participation we had quality of life, and under environmental factors, we had social support. So that's how we tried to design and put those outcome measures into our ICF domains.
- [07:03]
A
Nice. That's excellent. I should back up a little bit. Like, what studies did you include in thinking about Telerehab? Was it visual and audio? Was there? I saw something about extra gaming in there too. Would you be able to expand upon that?
- [07:20]
B
Yes, of course. That's a really good question. Because there is this huge umbrella term of terror rehabilitation. It can almost include everything. But the distinction that we had for our study, the inclusion criteria was to look at any type of exercise and physical activity and rehabilitation that was delivered over telecommunication technologies. Meaning that the therapist wasn't there in person. And the telecommunication technologies could be anything from remote based virtual reality and remote based exergaming and video conferencing platforms and mobile application telephone view conferencing platforms like Zoom. And so all of those could fall under the term telecommunication technologies. And we gathered the studies that had those kinds of interventions.
- [08:09]
A
Oh, that's excellent. Yeah, because it is kind of broad, right. Telerehab and how it's. It's billed as separately, I think, and how we can bill as therapists. But. But I feel like it can be expanded and maybe is starting to be expanded to include maybe things like remote therapeutic monitoring even. And maybe that's being included in the conversation here in the future.
- [08:31]
B
Yeah, maybe that's an interesting area that I see. It's getting the recognition. But yeah, for of course, maybe in the future.
- [08:39]
A
Maybe. Yeah. I have to see as that becomes a little bit more popular and widely used within rehabilitation.
- [08:45]
B
Yeah.
- [08:46]
A
Getting back to some of the outcomes that you were looking at, were most of the outcomes done virtually or were folks being brought back into the clinic for these assessments? Do you know?
- [08:59]
B
So I think for most of the studies the intervention part was done over telecommunication technologies and the assessment parts for most of them were done in person. And that was something that wasn't the focus of the paper to see if the assessment session was done in person or virtually. We were just interested in the intervention, but I think the assessment part for most of the papers was done in person.
- [09:24]
A
Oh yeah. Brought back in.
- [09:26]
B
Yeah.
- [09:27]
A
Interesting thought in my head, given the sort of standardization of many of these outcome measures, how folks are delivering these and if they can be administered over zoom or are folks being brought back in to the clinic, if that does exist, for them to come in.
- [09:45]
B
During this journey that I had from my class project in the systemic review here, and from what it became at the end for my master's thesis, I was looking at the validity of reliability of the core outcome measures that we assess in neural population when it's done over telecommunication technologies. And at the time I was not able to find good quality reliable studies to show that the outcome measures could be as reliable when they are done over telecommunication technologies. I think that's an area that definitely needs to be more researched. But because of that, I feel like the assessment part is still something that requires an in person session with a physical therapist.
- [10:30]
A
Right, right. That blend of both in person and telehealth seems to work well.
- [10:36]
B
Yeah, yes, true.
- [10:38]
A
You mentioned physical activity being one of the things that you were looking at in the systematic review, but it seemed when I was going through the paper there was some heterogeneity and sort of the outcome measures used. And could you speak more to that physical activity domain?
- [10:54]
B
Yes, I think we had three studies included in physical activity looking at the comparison between in person and telerhabilitation and we ended up not doing a meta analysis on the physical activity domain because of that heterogeneity. We had studies measuring physical activity through self reported outcome measures and we had studies reporting and recording physical activity through device measured ways of reporting that the amount of physical activity and through my research I found that there is not a strong correlation between self selected physical activity, self selected measures, physical activity and device measured physical activity. And so because of that we ended up not doing a meta analysis on that domain. But the results, I think two of the Studies were showing results in favor of telerhabilitation. One of the studies was in favor of telerhabilitation and two was showing comparable results. So yeah, that was, that was the problem we had with the physical activity still may.
- [11:58]
A
Right. Which becomes a challenge. Right. In certain patients. Let's think clinically, in the real world, some folks use activity monitors. Sometimes you have to rely on these self report measures. But interesting even that finding that maybe there isn't that strong correlation and we know there are discrepancies there in what folks report and what we actually see.
- [12:20]
B
True. We definitely had heterogeneity in the ways that the outcome measures were reported. Imbalance and gait and quality of life and physical activity. And we definitely heterogeneity in the type of control group that that study were comparing their interventions to. So those areas were the parts that it was hard to run the meta analysis and like to categorize the studies.
- [12:45]
A
Right, right. I guess. But going back to sort of the population that you were seeing within these reviews or within the studies included, what stage were these folks in Parkinson's disease? Were they mid to early stage? Were you able to capture any in the later stages?
- [13:05]
B
I think it was something that was just gathered through our search that we were seeing this pattern happening that the studies, the randomized controlled trials that were looking at this population, they were looking at the population in mild to moderate stages of the disease and not including the later stages of the disease disease. And that's an area that I definitely feel like there's a gap because one of those barriers, as I mentioned, could be the progressed disease symptoms and understanding how telerhabilitation can be effective for those. We definitely do need to research on the severe stages of the disease. I think there are so many things that we need to take into consideration. It's safety, it's the effectiveness of the intervention. It's just making sure that they can participate and they can benefit from this type of intervention. But that's also another gap that remains to be studied.
- [14:00]
A
Right, right. You know, unfortunately that is the case with many of these studies. We see folks with more milder disease are able to come in and participate. And maybe we're missing some of those folks with more progressed disease. But in the case of telerehab, it's an interesting concept. Right. Where maybe there is an opportunity to access these folks if there are transportation or mobility carriers that, that limit them from coming in.
- [14:28]
B
Yeah, I hope doing more research on the topic of tele rehabilitation and building the work of tele rehabilitation can be a method of delivery for mild to moderate stages of the disease. Could potentially give us the opportunity to move it further to analyze the same thing and the same concept for the individuals that are living with later stages of the disease. My hope is that moving this area forward, we get to do that also.
- [14:58]
A
Yeah, that'd be great. Guess in terms of talking about the effects of Telerehab on folks with Parkinson's disease, what were some of the findings within the systematic review?
- [15:10]
B
Yes. So the results were interesting. In the domains of icf, in the activities domain, and in the body function and structure, we saw that there are comparable from the statistical standpoint. Pulling the results together, there was not a statistically significant difference between the control group and the Telerehab group. But then, interestingly enough, in the participation domain, looking at quality of life, we were seeing the results favoring telerhabilitation. The results were statistically in favor of telerhabilitation. And this relationship was stronger when we were looking at non active control group subgroup analysis, and it was eliminated when we were looking at active control group subgroup analysis. But overall, the results were in favor of tele rehabilitation. And unfortunately, we were not able to gather studies that were looking at the effect of telerhabilitation on social support. So that's another gap that I hope to get the chance to study.
- [16:12]
A
Moving forward, it sounds like both in person and telerehab are comparable for the body structure and function and activity domain. But then Telerehab rose to the top in terms of participation and particularly quality of life.
- [16:29]
B
Yes. So there were some components of the interventions included in the quality of life section in the participation domain. They had consistent care, consistent monitoring of their participants. They had individualized treatments and individualized guidance. They had personalized and adaptive care. And I feel like for that domain, maybe those components of the interventions were potentially the reasons that we saw telerhabilitation being favored. So my take was that maybe moving forward, it's not an either or or that we use in person or telerhabilitation. So now maybe moving forward, we have this hybrid option that we see and look at and analyze our resources, our patient preferences, and if the focus of the treatment is in participation, then we can provide this type of treatment for them in this environment.
- [17:30]
A
I think that's an excellent takeaway and it's probably so true. Right. Where this blend of care maybe might work best for this population. But then including those factors that you said, like this individualized and personalized program, like those being the key ingredients that we all need to be thinking about when working with these folks.
- [17:51]
B
Yes, yes, I think those are very interesting takeaways and thank you for pointing them out. When I was looking at the results from my clinical standpoint, I was thinking that this is good news. Now we know that if our participants cannot come to our rehab sessions, if they have barriers, if there are something hindering them from coming to a regular exercise session and rehabilitation treatment, clinicians and physical therapists now can have the option to decide what type of, of care, what type of delivery of care can be best for their patients based on the resources and based on the patient preferences. There is this stigma around use of tele rehabilitation in this population and use of telehabilitation in general from physical therapist standpoint and from our patients standpoints where they feel like tele rehabilitation may just be an inferior option and not like their first choice. But it's important that we look at the evidence and we see what the evidence is showing us, that it may be one of our best options based on our patients preferences and our resources to be able to provide that care and support for our patients.
- [19:01]
A
I think you're absolutely right. There, there is kind of a stigma against it. Right. And folks maybe with balance trouble or, you know, we need to be there guarding and providing this care. But I think you're right. And systematic review had some, some good findings here. That, that does show that. And you mentioned something interesting too. Did you say that for the quality of life, the participation domain, it was more significant for the non active group versus the active group?
- [19:30]
B
Yes. So in the method we were saying that in a meta analysis, if we have more than three studies falling under one of our subgroups, we will do a subgroup analysis. We had heterogeneity in the control group. So we were looking at, generally we were looking at control groups that were not exposed to telerhabilitation. But then within that we had non active control groups that were not receiving any type of exercise, any type of rehabilitation. They were the control groups that were continuing with the usual care. But the active control groups were the control groups that were receiving in person rehabilitation or they were receiving home exercise programs or exercise booklets and then doing the subgroup analysis. The results were stronger when we were looking at non active control group. But again when we were bringing in the active control group that the ones that are actually engaging and evolving, again, the results was just comparable. At the end the result was superior, favoring telerehabilitation in general. But when we took out the non active control groups and we were just looking at the active control groups. The results were still comparable and not inferior.
- [20:47]
A
Okay, so still positive. Right. We know that both telerehab and in person rehab work, but in general rehab works when we're seeing these folks.
- [20:56]
B
Yes, true.
- [20:57]
A
Very good. Was there any particular type of telerhab that you found was favorable? Like you mentioned, there was some heterogeneity and how it was delivered. Right. Did that come up in any of the subgroup analysis?
- [21:12]
B
So we had heterogeneity in the type of tele rehabilitation. It was anything from remote based virtual reality and remote based exergaming. And the reason I say and emphasize on remote based exergaming and virtual reality is that we often see virtual reality and XR gaming being used in this area, but they're not necessarily telehealthation. Sometimes they're just in clinic doing those types of interventions. So in our intervention, the type of tele rehabilitation, we had anything from telephone monitoring, remote based virtual reality, remote based XR gaming, mobile applications, video conferencing platforms, and it was all, all of those different types of intervention that we could have. But for the subgroup analysis, we didn't do a subgroup analysis to see what type of intervent, what type of telecommunication technology was favored. The subgroup analysis was related to the control group. But I think that's a really interesting thing to do more research on to see if one type is favoring another.
- [22:19]
A
Right. Just interesting. As I'm thinking what do I have access to in the clinic? And it's this more like a video conferencing. Right. Am I'm able to use. So it would be interesting to see do differences exist between that video conferencing or extra gaming or virtual reality delivered, you know.
- [22:38]
B
Yes, lots to research.
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A
Lots of research areas.
- [22:41]
B
Yes.
- [22:42]
A
Yeah. Yeah. And kind of thinking we're in our, our infancy with this. Right. It's only been so many years since this really started to be implemented. So exciting to see maybe where this will, will lead and open opportunities for, for us as therapists and for people with, with various neurologic diseases, including Parkinson's.
- [23:01]
B
Yes, definitely. There's still lots of areas that remains to be researched and studied more and to be underst. I think understanding what type of telerehab might be favored is definitely one of them.
- [23:13]
A
Yeah. What do you think in terms of implementing this in the clinic for folks with Parkinson's disease? What barriers exist, let's say, for people with Parkinson's disease to utilize telerehab?
- [23:30]
B
So there's so many things I feel like one important aspect would be the social support that they're receiving and we don't have enough evidence to see if they're feeling the same or not. One aspect could be the human interaction, how they may enjoy the human interaction that they have with their physical therapist, maybe they're with their exercise partners if they're coming to an exercise class. All of those different things that just may not that haven't been measured in telerhabilitation can be an important part of that.
- [24:05]
A
Yeah, and you mentioned. And were you looking at social support at all?
- [24:10]
B
Yes, it was under my environmental factors domain to look at social support and unfortunately we couldn't find the studies that were looking at the effect of tele rehabilitation on social support. However, the evidence is showing that in person interaction is a source of support and the evidence in neural population is showing that the in person interaction from healthcare provider can help participants and facilitate their participation and adherence to their exercise. So there is that on the in person aspect and there's also specific to the field of Parkinson's disease, there's also research showing that social support can improve physical activity in this population. But then my question would be that, so how would things change if we switch into a virtual session, if we switch into telerhabilitation? And I think that's really important to understand how social support is perceived and understood from a patient's perspective in that area.
- [25:16]
A
That is interesting just because when I first think of social support, I think of family, friends, that they're able to maybe assist with rehab or support them within the community. But rethinking it now, like us as therapists and providers, provide that social support. Definitely interesting to think about that.
- [25:37]
B
Yeah. I think during a rehab, like usual rehab session or usual physical therapy session, you have the opportunity to talk and make human interaction. You have this opportunity to communicate and like build this connection with them. And it changes so many things. Changes when you are switching into a virtual environment and you're just seeing them through any screen. So I feel like that could be something that may not be a favorable part maybe from a patient's perspective to come to a virtual environment. But that needs to be studied. We'll see.
- [26:15]
A
We'll see, right? Yeah. Because thinking when you go to an in person visit, you're interacting with the other patients, maybe in the waiting room, you're interacting with the front desk and your therapist.
- [26:25]
B
Yeah, yeah.
- [26:26]
A
Just kind of interesting there. But we'll have to see. And now, now flipping it too. We just spoke about the barriers for people with Parkinson's disease to implement telerehab. But what about the providers? Like, did that come up at all within the study? Were there barriers to implementing telerehab from a provider standpoint?
- [26:45]
B
It didn't come up in the studies. So the barriers from a physical therapist perspective didn't come up there. But I feel like the barriers from a physical therapy perspective could be that they don't get to like, see the patients and assess the patients. As we were discussing earlier, the evidence is lacking in that area. And sometimes physical therapists don't feel comfortable switching to that virtual environment because they don't get to observe their patients as they walk into the doors. They don't get to see them, how they're feeling. They don't get to assess them. They don't get to measures all of those. All of those different things that physical therapists can feel and understand by just looking at their patients, that may not be a part of their outcome measures. So I feel like from a physical therapist standpoint, it may be that also a hybrid version would be preferred, but I feel like those could be something like barriers for physical therapists to engage in telerhabitation.
- [27:45]
A
Yeah, yeah. Another. Another area of research potentially to see how we can best optimize telerehab and utilize it within the clinic, how we can address said barriers.
- [27:56]
B
Yes, true.
- [27:58]
A
Anything else that you wanted to touch upon?
- [28:01]
B
So moving forward, I hope to see more mixed methods studies or qualitative studies trying to understand from a patient's perspective how they're feeling toward tele rehabilitation and also from a physical therapist perspective. But I feel like we touched upon the important concepts and components of the research.
- [28:24]
A
I think so too. And say I'm more apt to use telerehab knowing that there is a little bit of evidence behind it now. And yes, it is a little bit of a learning curve when you're using it though, and transitioning to in. From in person to telerehab. So getting in a group can be helpful.
- [28:41]
B
True.
- [28:42]
A
One last question we have for you is. Is really a tradition here on the DD sig where we ask each of our guests what they like to do outside of work. Work. So what is it that you like to do when you're not working?
- [28:54]
B
That's. That's an interesting and lovely question. So I love pottery. I love to do pottery on a wheel. I think when the clay is centered on the wheel, it's just like all of my problems is kind of solved now. So I love doing pottery, I love swimming, and I love my social network. Coming back to the social support. I think having that connection, hanging out with your friends and the people that are going through the same thing, my friends here at UConn, I feel like that's, that's, that really helps me to move through and, like, get through this.
- [29:32]
A
That's excellent. All right, well, thanks so much for coming on for. It is absolutely wonderful to talk to you about your, your poster and your systematic review, really. So congratulations again.
- [29:45]
B
Thank you. Lastly, if I have the chance, I just want to acknowledge all of my amazing co authors, Dr. Danielle Piscatelli, Dr. James Smith, Dr. Linda Pescatello, and my amazing mentor, Dr. Cristina Cloncimenza and Alessandro Ucculini that helped me get through the statistical part. So I just want to acknowledge them, thank them for their patience and for the support and guidance.
- [30:08]
A
Wonderful, wonderful. Thanks so much for coming on again.
- [30:12]
B
Thank you. I really appreciate it.
- [30:14]
A
Thanks for joining us. Special thanks to our guest today, Pariah Darbhanzari. This podcast was produced and edited by the ANPT Degenerative Diseases Special Interest Group podcast team. For more information on the SIG and ANPT, visit www.neuropt.org. our podcast team includes Sara Zoller, Christina Burke, Karm Padgett, Madison Catalano, Aisha Sonani and Ayn Ken Vanak. Thanks to Olivia Visagio who helped with article review for this podcast. Thanks to Jimmy McKay for providing music and please share this episode with a colleague today. Make sure we get all the good content, even the bloopers. We have a lot of representation here. From New England states, too. Shoot. Mass, Rhode Island, Connecticut. Aisha, are you from New England?
- [31:04]
B
I'm from Jersey. I don't know if that counts.
- [31:06]
A
Northeast doesn't count. I'm sorry, but
- [31:11]
B
that was probably a good copy paste error right there. Is it just me as a Ken? No, it's him.
- [31:19]
A
No. Ever hang out at the dairy barn at UConn? I know that's a. We do some ice cream, some basketball on the men's side.
- [31:32]
B
Yes.
- [31:32]
A
Both very good.
- [31:33]
B
Proud of the basketball world. Basketball world. Capital. Yes. Guess. New nominating committee.
- [31:41]
A
The sole person running.
- [31:43]
B
Hey, take it.