Physiotherapy and Deep Brain Stimulation in Parkinson's Disease

The primary outcome is the overall amount of independent mobility in the community. This will be measured with the Life Space Assessment (LSA) questionnaire. The LSA is a five-item questionnaire where participants are asked to indicate how often within the previous four weeks they moved within their homes, outside their homes but within their property, within their neighborhoods, within their towns, and outside their towns. LSA is a cross-sectional scale that quantifies the size of one's life space in the past 4 weeks as a score of 0-120 (0 = confined to the bedroom, 120 = daily travel to places outside of one's city/town).

The Mini Balance Evaluation Systems Test (Mini-BESTest) will be used to measure dynamic balance. The Mini-BESTest is a 14-item test that includes four sections: anticipatory postural adjustments, reactive postural control, sensory orientation, and dynamic gait. Each item is scored from 0-2 (0 indicates that a person is unable to perform the task while a score of 2 is normal).

Dynamic stability during walking, spatio-temporal gait variability and walking speed will be evaluated using the gait mat Zeno Walkway (ProtoKinetics, Havertown, PA, USA).

Balance confidence will be assessed using the Activity-specific Balance Confidence (ABC) scale. The ABC asks participants to rate, on a scale from 0-100%, how confident they would be performing 16 everyday tasks.

Participants will be provided with a diary on enrolment into the study and will be asked to record any falls and near falls that they experience over the 8 months' duration of the study. A fall is defined as an event that result in a person coming to rest inadvertently on the ground or other lower level not due to a major intrinsic or extrinsic event. If a participant sustains a fall, they will be asked to record the details about the circumstances surrounding the fall with an open-ended questionnaire (setting, activity at the time of fall, physical injury, emergency department visit, hospitalization) in the falls diary. A near fall is defined as stumbling or loss of balance that would result in falling if sufficient recovery mechanisms were not activated. If the participant had a near fall, they will be asked to record the details about the event using the same open-ended questionnaire (setting, activity at the time of near fall, how the fall was avoided) in the diary.

The Timed Up and Go test (TUG) will be used to assess the falls risk and functional mobility. The TUG test is a physical performance measure in which the ability to rise up from a seated chair position, walk 3m, turn, walk back, and sit down is timed. The TUG test is highly correlated with functional mobility, gait speed, and falls in older adults.

Mood will be assessed using the Beck Depression Inventory (BDI-I).The BDI-I is a 21-item questionnaire to assess depressive symptoms with a score of 0-3 for each item.

The Hamilton Anxiety Rate Scale (HAM-A) will be used to measure the anxiety symptoms. The scale consists of 14 items with a score of 0-4 for each item.

Exercise and activity levels will be monitored through a set of questions about how much exercise or physical activity they do on a regularly. For the intensity of the activity, they will be asked to separate how much time they spend doing vigorous, moderate, and light activity.

Health-related quality of life will be assessed using the 39-item Parkinson's Disease Questionnaire (PDQ-39). The PDQ-39 asks participants to rate how often they encounter difficulty on items within eight subscales: mobility, activities of daily living, emotional well-being, stigma, social support, cognition, communication, and bodily discomfort.

Parkinson's disease symptoms will be evaluated with the Movement Disorders Society Unified Parkinson Disease Rating Scale (MDS-UPDRS) part 3 scores. The maximum total MDS-UPDRS score for part 3 ranges from 0 to 132. Higher scores indicate a worse outcome of Parkinson's disease.

A wearable activity monitor Fitbit Inspire 2 (Fitbit Inc., San Francisco, CA, USA) will be used to measure the average number of steps (the total number of steps per day averaged over the number of days worn). The participants will be provided with a Fitbit Inspire 2 activity monitor before the pre-intervention assessment at 3 months and the post-intervention assessment at 6 months. They will be instructed to wear the activity monitor on their wrist for 7 days including during sleep before the assessment visits.

A wearable activity monitor Fitbit Inspire 2 (Fitbit Inc., San Francisco, CA, USA) will be used to measure the distance (kilometers). The participants will be provided with a Fitbit Inspire 2 activity monitor before the pre-intervention assessment at 3 months and the post-intervention assessment at 6 months. They will be instructed to wear the activity monitor on their wrist for 7 days including during sleep before the assessment visits.

A wearable activity monitor Fitbit Inspire 2 (Fitbit Inc., San Francisco, CA, USA) will be used to measure the time being physically active. The participants will be provided with a Fitbit Inspire 2 activity monitor before the pre-intervention assessment at 3 months and the post-intervention assessment at 6 months. They will be instructed to wear the activity monitor on their wrist for 7 days including during sleep before the assessment visits.

A wearable activity monitor Fitbit Inspire 2 (Fitbit Inc., San Francisco, CA, USA) will be used to measure the heart rate (rates per minute). The participants will be provided with a Fitbit Inspire 2 activity monitor before the pre-intervention assessment at 3 months and the post-intervention assessment at 6 months. They will be instructed to wear the activity monitor on their wrist for 7 days including during sleep before the assessment visits.

A wearable activity monitor Fitbit Inspire 2 (Fitbit Inc., San Francisco, CA, USA) will be used to measure sleep quality (minutes). The participants will be provided with a Fitbit Inspire 2 activity monitor before the pre-intervention assessment at 3 months and the post-intervention assessment at 6 months. They will be instructed to wear the activity monitor on their wrist for 7 days including during sleep before the assessment visits.