iVOMS: Instrumented Vestibular / Ocular motor screen in healthy controls and mild traumatic brain injury.

Objective Vestibular/ocular deficits occur with mild traumatic brain injury (mTBI). The vestibular/ocular motor screening (VOMS) tool is used to assess individuals post-mTBI, which primarily relies upon subjective self-reported symptoms. Instrumenting the VOMS (iVOMS) with technology may allow for more objective assessment post-mTBI, which reflects actual task performance. This study aimed to validate the iVOMS analytically and clinically in mTBI and controls. Methods Seventy-nine people with sub-acute mTBI (<12 weeks post-injury) and forty-four healthy control participants performed the VOMS whilst wearing a mobile eye-tracking on a one-off visit. People with mTBI were included if they were within 12 weeks of a physician diagnosis. Participants were excluded if they had any musculoskeletal, neurological or sensory deficits which could explain dysfunction. A series of custom-made eye tracking algorithms were used to assess recorded eye-movements. Results The iVOMS was analytically valid compared to the reference (ICC2,1 0.85-0.99) in mTBI and controls. The iVOMS outcomes were clinically valid as there were significant differences between groups for convergence, vertical saccades, smooth pursuit, vestibular ocular reflex and visual motion sensitivity outcomes. However, there was no significant relationship between iVOMS outcomes and self-reported symptoms. Conclusion The iVOMS is analytically and clinically valid in mTBI and controls, but further work is required to examine the sensitivity of iVOMS outcomes across the mTBI spectrum. Findings also highlighted that symptom and physiological issue resolution post-mTBI may not coincide and relationships need further examination.

Contextualizing remote fall risk: Video data capture and implementing ethical AI.

Wearable inertial measurement units (IMUs) are being used to quantify gait characteristics that are associated with increased fall risk, but the current limitation is the lack of contextual information that would clarify IMU data. Use of wearable video-based cameras would provide a comprehensive understanding of an individual's habitual fall risk, adding context to clarify abnormal IMU data. Generally, there is taboo when suggesting the use of wearable cameras to capture real-world video, clinical and patient apprehension due to ethical and privacy concerns. This perspective proposes that routine use of wearable cameras could be realized within digital medicine through AI-based computer vision models to obfuscate/blur/shade sensitive information while preserving helpful contextual information for a comprehensive patient assessment. Specifically, no person sees the raw video data to understand context, rather AI interprets the raw video data first to blur sensitive objects and uphold privacy. That may be more routinely achieved than one imagines as contemporary resources exist. Here, to showcase/display the potential an exemplar model is suggested via off-the-shelf methods to detect and blur sensitive objects (e.g., people) with an accuracy of 88%. Here, the benefit of the proposed approach includes a more comprehensive understanding of an individual's free-living fall risk (from free-living IMU-based gait) without compromising privacy. More generally, the video and AI approach could be used beyond fall risk to better inform habitual experiences and challenges across a range of clinical cohorts. Medicine is becoming more receptive to wearables as a helpful toolbox, camera-based devices should be plausible instruments.

Coproduction and Usability of a Smartphone App for Falls Reporting in Parkinson Disease.

OBJECTIVE: The purpose of this study was to coproduce a smart-phone application for digital falls reporting in people with Parkinson disease (PD) and to determine usability using an explanatory mixed-methods approach. METHODS: This study was undertaken in 3 phases. Phase 1 was the development phase, in which people with PD were recruited as co-researchers to the project. The researchers, alongside a project advisory group, coproduced the app over 6 months. Phase 2 was the implementation phase, in which 15 people with PD were invited to test the usability of the app. Phase 3 was the evaluation phase, in which usability was assessed using the systems usability scale by 2 focus groups with 10 people with PD from phase 2. RESULTS: A prototype was successfully developed by researchers and the project advisory group. The usability of the app was determined as good (75.8%) by people with PD when rating using the systems usability scale. Two focus groups (n = 5 per group) identified themes of 1) usability, 2) enhancing and understanding management of falls, and 3) recommendations and future developments. CONCLUSIONS: A successful prototype of the iFall app was developed and deemed easy to use by people with PD. The iFall app has potential use as a self-management tool for people with PD alongside integration into clinical care and research studies. IMPACT: This is the first digital outcome tool to offer reporting of falls and near-miss fall events. The app may benefit people with PD by supporting self-management, aiding clinical decisions in practice, and providing an accurate and reliable outcome measure for future research. LAY SUMMARY: A smartphone application designed in collaboration with people who have PD to record their falls was acceptable and easy to use by people with PD.

Exploring mobility dysfunction in people with and without impaired cognition in Parkinson disease.

INTRODUCTION: The relationship between mobility and cognition has been studied in the aging population and associations have been also reported in people with Parkinson's disease (PD). OBJECTIVE: To compare different aspects of gait and balance between individuals with PD who have normal cognition and those with impaired cognition, using both clinical and instrumented measures. METHODS: One-hundred forty-three participants with PD were divided into two groups: 1) normal cognition (n = 71) and 2) impaired cognition (n = 72) based on the Montreal Cognitive Assessment (MoCA) cut-off. Groups were compared using instrumented and clinical measures of gait and balance in the following domains: Sensory Orientation, Anticipatory Postural Adjustments, Automatic Postural Responses and Dynamic Balance for Gait. Instrumented measures were obtained via wearable sensors while performing eight different motor tasks and clinical measures were obtained with the Mini-BESTest. RESULTS: The total Mini-BESTest score was not different between groups. However, the Dynamic Gait domain was worse in individuals with impaired cognition. Among the instrumented measures across domains, all significant group differences were in the Dynamic Gait domain, specifically, dual-task gait speed, dual-task stride length, stance time, and turn velocity. CONCLUSIONS: Dynamic balance during gait was more impaired in people with PD who had abnormal cognition than those with normal cognition, for both clinical and instrumented measures. All other balance domains did not differ between groups, for both instrumented and clinical measures.

Visual Exploration While Walking With and Without Visual Cues in Parkinson's Disease: Freezer Versus Non-Freezer.

BACKGROUND: Visual cues can improve gait in Parkinson's disease (PD), including those experiencing freezing of gait (FOG). However, responses are variable and underpinning mechanisms remain unclear. Visuo-cognitive processing (measured through visual exploration) has been implicated in cue response, but this has not been comprehensively examined. OBJECTIVE: To examine visual exploration and gait with and without visual cues in PD who do and do not self-report FOG, and healthy controls (HC). METHODS: 17 HC, 21 PD without FOG, and 22 PD with FOG walked with and without visual cues, under single and dual-task conditions. Visual exploration (ie, saccade frequency, duration, peak velocity, amplitude, and fixation duration) was measured via mobile eye-tracking and gait (ie, gait speed, stride length, foot strike angle, stride time, and stride time variability) with inertial sensors. RESULTS: PD had impaired gait compared to HC, and dual-tasking made gait variables worse across groups (all P < .01). Visual cues improved stride length, foot strike angle, and stride time in all groups (P < .01). Visual cueing also increased saccade frequency, but reduced saccade peak velocity and amplitude in all groups (P < .01). Gait improvement related to changes in visual exploration with visual cues in PD but not HC, with relationships dependent on group (FOG vs non-FOG) and task (single vs dual). CONCLUSION: Visual cues improved visual exploration and gait outcomes in HC and PD, with similar responses in freezers and non-freezers. Freezer and non-freezer specific associations between cue-related changes in visual exploration and gait indicate different underlying visuo-cognitive processing within these subgroups for cue response.

Ocular microtremor: a structured review.

Ocular microtremor (OMT) is the smallest of three involuntary fixational micro eye movements, which has led to it being under researched in comparison. The link between OMT and brain function generates a strong rationale for further study as there is potential for its use as a biomarker in populations with neurological injury and disease. This structured review focused on populations previously studied, instrumentation used for measurement, commonly reported OMT outcomes, and recommendations concerning protocol design and future studies. Current methods of quantifying OMT will be reviewed to analyze their efficacy and efficiency and guide potential development and understanding of novel techniques. Electronic databases were systematically searched and compared with predetermined inclusion criteria. 216 articles were identified in the search and screened by two reviewers. 16 articles were included for review. Findings showed that piezoelectric probe is the most common method of measuring OMT, with fewer studies involving non-invasive approaches, such as contact lenses and laser imaging. OMT frequency was seen to be reduced during general anesthesia at loss of consciousness and in neurologically impaired participants when compared to healthy adults. We identified the need for a non-invasive technique for measuring OMT and highlight its potential in clinical applications as an objective biomarker for neurological assessments. We highlight the need for further research on the clinical validation of OMT to establish its potential to identify or predict a meaningful clinical or functional state, specifically, regarding accuracy, precision, and reliability of OMT.

Stroboscopic visual training: The potential for clinical application in neurological populations.

Visual problems are common in people who have neurological injury or disease, with deficits linked to postural control and gait impairment. Vision therapy could be a useful intervention for visual impairment in various neurological conditions such as stroke, head injury, or Parkinson's disease. Stroboscopic visual training (SVT) has been shown to improve aspects of visuomotor and cognitive performance in healthy populations, but approaches vary with respect to testing protocols, populations, and outcomes. The purpose of this structured review was to examine the use of strobe glasses as a training intervention to inform the development of robust protocols for use in clinical practice. Within this review, any studies using strobe glasses as a training intervention with visual or motor performance-related outcomes was considered. PubMed, Scopus, and ProQuest databases were searched in January 2023. Two independent reviewers (JD and RM) screened articles that used strobe glasses as a training tool. A total of 33 full text articles were screened, and 15 met inclusion/exclusion criteria. Reported outcomes of SVT included improvements in short-term memory, attention, and visual response times, with emerging evidence for training effects translating to balance and physical performance. However, the lack of standardisation across studies for SVT protocols, variation in intervention settings, duration and outcomes, and the limited evidence within clinical populations demonstrates that further work is required to determine optimal strobe dosage and delivery. This review highlights the potential benefits, and existing research gaps regarding the use of SVT in clinical practice, with recommendations for clinicians considering adopting this technology as part of future studies in this emerging field.

Yoga and Multiple Sclerosis: Maintaining engagement in physical activity.

BACKGROUND: Physical activity is encouraged for people with Multiple Sclerosis. Yoga is a popular form of physical activity and is chosen by some people with Multiple Sclerosis. However, little is known about the impact of yoga for this population, alongside what influences ongoing engagement. AIM: The aim of this study is to qualitatively explore the impact of online home-based yoga on people with Multiple Sclerosis and to explore factors that influence engagement. METHODS: A qualitative study using semi-structured interviews and focus groups with people with Multiple Sclerosis and a yoga teacher. Thematic analysis was used to analyse the data. Ethical Approval was gained from Northumbria University. FINDINGS: Three overarching themes emerged from the analysis. 'Yoga as engagement in physical activity' captured the reasoning for participating in yoga and how this method of physical activity was an alternative to physical activity done prior to diagnosis. Frustration was apparent within this theme that some individuals were unable to engage in the range of physical activity that they wished to. 'Yoga is a personalised approach' demonstrated the flexibility and inclusivity of yoga, for individuals with varying symptoms to be able to engage with. Finally, 'yoga impacts individuals both physically and psychologically' captured the focus on the psychological impact of yoga, improving wellbeing and control. CONCLUSIONS: Yoga gives people with Multiple Sclerosis the feeling of control over their symptoms and a means to engage with meaningful physical activity. Prior involvement in physical activity influenced engagement in yoga and wanting to push themselves. There was reluctance among this group to engage with aerobic activity, which warrants future investigation and support from health and exercise professionals.

Combination of Clinical and Gait Measures to Classify Fallers and Non-Fallers in Parkinson's Disease.

Although the multifactorial nature of falls in Parkinson's disease (PD) is well described, optimal assessment for the identification of fallers remains unclear. Thus, we aimed to identify clinical and objective gait measures that best discriminate fallers from non-fallers in PD, with suggestions of optimal cutoff scores. METHODS: Individuals with mild-to-moderate PD were classified as fallers (n = 31) or non-fallers (n = 96) based on the previous 12 months' falls. Clinical measures (demographic, motor, cognitive and patient-reported outcomes) were assessed with standard scales/tests, and gait parameters were derived from wearable inertial sensors (Mobility Lab v2); participants walked overground, at a self-selected speed, for 2 min under single and dual-task walking conditions (maximum forward digit span). Receiver operating characteristic curve analysis identified measures (separately and in combination) that best discriminate fallers from non-fallers; we calculated the area under the curve (AUC) and identified optimal cutoff scores (i.e., point closest-to-(0,1) corner). RESULTS: Single gait and clinical measures that best classified fallers were foot strike angle (AUC = 0.728; cutoff = 14.07°) and the Falls Efficacy Scale International (FES-I; AUC = 0.716, cutoff = 25.5), respectively. Combinations of clinical + gait measures had higher AUCs than combinations of clinical-only or gait-only measures. The best performing combination included the FES-I score, New Freezing of Gait Questionnaire score, foot strike angle and trunk transverse range of motion (AUC = 0.85). CONCLUSION: Multiple clinical and gait aspects must be considered for the classification of fallers and non-fallers in PD.

The integration of technology into a home-based visuo-cognitive training intervention for people with Parkinson's: Is the future digital?

BACKGROUND: Mobile applications and technology (e.g., stroboscopic glasses) are increasingly being used to deliver combined visual and cognitive (termed visuo-cognitive) training that replaces standard pen and paper-based interventions. These 'technological visuo-cognitive training' (TVT) interventions could help address the complex problems associated with visuo-cognitive dysfunction in people with long term neurological conditions such as Parkinson's disease. As data emerges to support the effectiveness of these technologies, patient perspectives offer an insight into how novel TVT is received by people living with long term neurological conditions. OBJECTIVE: To explore experiences of people with Parkinson's in using technology as part of a home-based visuo-cognitive training programme compared to traditional approaches to rehabilitation. METHODS: Eight people with Parkinson's who took part in a pilot randomised cross-over trial, investigating the efficacy and feasibility of TVT compared to standard care, were interviewed to explore their experiences of each arm of the training they received. Integration of Normalisation Process Theory (NPT) into the analysis enabled examination of the potential to embed novel TVT into a home-based rehabilitation intervention for people with Parkinson's disease. RESULTS: Three key themes emerged from the thematic analysis as factors influencing the implementation potential of TVT for people with Parkinson's disease: perceived value of technology, perceived ease of use and support mechanisms. Further examination of the data through the lens of NPT revealed that the implantation and embedding of novel technology was dependent on positive user experience, individual disease manifestation and engagement with a professional. CONCLUSIONS: Our findings provide insights into the challenges of engaging with technology-based interventions while living with a progressive and fluctuating disease. When implementing technology-based interventions for people with Parkinson's, we recommend that patients and clinicians collaborate to determine whether the technology fits the capacity, preference, and treatment needs of the individual patient.

Gait and balance in apolipoprotein Ɛ4 allele carriers in older adults and Parkinson's disease.

Background: Gait and balance impairments are among the most troublesome and heterogeneous in Parkinson's disease (PD). This heterogeneity may, in part, reflect genetic variation. The apolipoprotein E (APOE) gene has three major allelic variants (ε2, ε3 and ε4). Previous work has demonstrated that older adult (OA) APOE ε4 carriers demonstrate gait deficits. This study compared gait and balance measures between APOE ε4 carriers and non-carriers in both OA and PD. Methods: 334 people with PD (81 APOE ε4 carriers and 253 non-carriers) and 144 OA (41 carriers and 103 non-carriers) were recruited. Gait and balance were assessed using body-worn inertial sensors. Two-way analyses of covariance (ANCOVA) compared gait and balance characteristics between APOE ε4 carriers and non-carriers in people with PD and OA, controlling for age, gender, and testing site. Results: Gait and balance were worse in people with PD compared to OA. However, there were no differences between APOE ε4 carriers and non-carriers in either the OA or PD group. In addition, there were no significant group (OA/PD) by APOE ε4 status (carrier/non-carrier) interaction effects for any measures of gait or balance. Conclusions: Although we found expected impairments in gait and balance in PD compared to OA, gait and balance characteristics did not differ between APOE ε4 carriers and non-carriers in either group. While APOE status did not impact gait and balance in this cross-sectional study, future work is needed to determine whether progression of gait and balance deficits is faster in PD APOE Ɛ4 carriers.

IoT-Enabled Gait Assessment: The Next Step for Habitual Monitoring.

Walking/gait quality is a useful clinical tool to assess general health and is now broadly described as the sixth vital sign. This has been mediated by advances in sensing technology, including instrumented walkways and three-dimensional motion capture. However, it is wearable technology innovation that has spawned the highest growth in instrumented gait assessment due to the capabilities for monitoring within and beyond the laboratory. Specifically, instrumented gait assessment with wearable inertial measurement units (IMUs) has provided more readily deployable devices for use in any environment. Contemporary IMU-based gait assessment research has shown evidence of the robust quantifying of important clinical gait outcomes in, e.g., neurological disorders to gather more insightful habitual data in the home and community, given the relatively low cost and portability of IMUs. The aim of this narrative review is to describe the ongoing research regarding the need to move gait assessment out of bespoke settings into habitual environments and to consider the shortcomings and inefficiencies that are common within the field. Accordingly, we broadly explore how the Internet of Things (IoT) could better enable routine gait assessment beyond bespoke settings. As IMU-based wearables and algorithms mature in their corroboration with alternate technologies, such as computer vision, edge computing, and pose estimation, the role of IoT communication will enable new opportunities for remote gait assessment.

Internet-of-Things-Enabled Markerless Running Gait Assessment from a Single Smartphone Camera.

Running gait assessment is essential for the development of technical optimization strategies as well as to inform injury prevention and rehabilitation. Currently, running gait assessment relies on (i) visual assessment, exhibiting subjectivity and limited reliability, or (ii) use of instrumented approaches, which often carry high costs and can be intrusive due to the attachment of equipment to the body. Here, the use of an IoT-enabled markerless computer vision smartphone application based upon Google's pose estimation model BlazePose was evaluated for running gait assessment for use in low-resource settings. That human pose estimation architecture was used to extract contact time, swing time, step time, knee flexion angle, and foot strike location from a large cohort of runners. The gold-standard Vicon 3D motion capture system was used as a reference. The proposed approach performs robustly, demonstrating good (ICC(2,1) > 0.75) to excellent (ICC(2,1) > 0.90) agreement in all running gait outcomes. Additionally, temporal outcomes exhibit low mean error (0.01−0.014 s) in left foot outcomes. However, there are some discrepancies in right foot outcomes, due to occlusion. This study demonstrates that the proposed low-cost and markerless system provides accurate running gait assessment outcomes. The approach may help routine running gait assessment in low-resource environments.

Bespoke Fuzzy Logic Design to Automate a Better Understanding of Running Gait Analysis.

Running gait assessment and running shoe recommendation is important for the injury prevention of runners who exhibit different skill-levels and running styles. Traditionally, running gait assessment for shoe recommendation relies upon a combination of trained professionals (e.g., sports-therapists, physiotherapists) and complex equipment such as motion or pressure sensors, often incurring a high-cost to the consumer. Despite this, assessments are still prone to subjectivity, and may differ between assessors. Alternatively, methods to provide low-cost, reproduceable gait assessment has become a necessity, especially within a habitual (low-resource) context, with many traditional methods generally unavailable due to the need of professional assistance and more recently the COVID-19 pandemic. Fuzzy logic has shown to be an effective tool in the assessment and identification of gait by providing the potential for a high-accuracy methodology, while retaining a low computational cost; ideal for applications within embedded systems. Here, we present a novel shoe recommendation fuzzy inference system from the classification of two key running gait parameters, foot strike and pronation from a single foot mounted internet of thing (IoT) enabled wearable inertial measurement unit. The fuzzy approach provides excellent (ICC > 0.9) accuracy, while significantly increasing the resolution of the gait assessment technique, providing a more detailed running gait analysis.

Exploring the effects of dopamine on sensorimotor inhibition and mobility in older adults.

Dopaminergic activity decreases in older adults (OAs) with normal aging and is further reduced in Parkinson's disease (PD), affecting cortical motor and sensorimotor pathways. Levodopa is the prevailing therapy to counter dopamine loss in PD, though not all PD motor signs improve with levodopa. The purpose of this preliminary study was to explore the effects of levodopa on sensorimotor inhibition, gait and quiet standing in OAs and to investigate the relationships between sensorimotor inhibition and both gait and standing balance both OFF- and ON-levodopa. Fifteen OA males completed a gait, balance and sensorimotor assessments before and 1 h after they were given a 100 mg dose of levodopa. Short-latency afferent inhibition quantified sensorimotor inhibition. Wearable sensors characterized gait (two-minute walk) and standing balance (1-min stance). No sensorimotor inhibition, gait, or standing balance measures changed from OFF- to ON-levodopa. When OFF-levodopa, worse inhibition significantly related to increased double stance (r = 0.62; p = 0.01), increased jerkiness of sway (r = 0.57; p = 0.03) and sway area (r = 0.58; p = 0.02). While ON-levodopa, worse inhibition related to increased arm swing range of motion (r = 0.63; p = 0.01) and jerkiness of sway (r = 0.53; p = 0.04). The relationship between SAI and arm swing excursion significantly changed from OFF- to ON-levodopa (z = - 3.05; p = 0.002; 95% confidence interval = - 0.95, - 0.21). Sensorimotor inhibition relationships to both gait and balance may be affected by dopamine in OAs. Cortical restructuring due to the loss of dopamine may be responsible for the heterogeneity of levodopa effect in people with PD and OAs.

Suitability of a Low-Cost Wearable Sensor to Assess Turning in Healthy Adults.

Background: Turning is a complex measure of gait that accounts for over 50% of daily steps. Traditionally, turning has been measured in a research grade laboratory setting, however, there is demand for a low-cost and portable solution to measure turning using wearable technology. This study aimed to determine the suitability of a low-cost inertial sensor-based device (AX6, Axivity) to assess turning, by simultaneously capturing and comparing to a turn algorithm output from a previously validated reference inertial sensor-based device (Opal), in healthy young adults. Methodology: Thirty participants (aged 23.9 ± 4.89 years) completed the following turning protocol wearing the AX6 and reference device: a turn course, a two-minute walk (including 180° turns) and turning in place, alternating 360° turn right and left. Both devices were attached at the lumbar spine, one Opal via a belt, and the AX6 via double sided tape attached directly to the skin. Turning measures included number of turns, average turn duration, angle, velocity, and jerk. Results: Agreement between the outcomes from the AX6 and reference device was good to excellent for all turn characteristics (all ICCs > 0.850) during the turning 360° task. There was good agreement for all turn characteristics (all ICCs > 0.800) during the two-minute walk task, except for moderate agreement for turn angle (ICC 0.683). Agreement for turn outcomes was moderate to good during the turns course (ICCs range; 0.580 to 0.870). Conclusions: A low-cost wearable sensor, AX6, can be a suitable and fit-for-purpose device when used with validated algorithms for assessment of turning outcomes, particularly during continuous turning tasks. Future work needs to determine the suitability and validity of turning in aging and clinical cohorts within low-resource settings.

Brain activity response to cues during gait in Parkinson's disease: A study protocol.

Various cueing strategies (internal and external) have been used to alleviate gait deficits in Parkinson's disease (PD). However, it remains unclear which type of cueing strategy is most effective at different disease stages or with more severe walking impairment, such as freezing of gait (FOG). The underlying neural mechanisms of response to cueing are also unknown. This trial aims to: (i) determine brain activity response to cue stimulus (internal, visual, auditory or tactile) when walking in PD and; (ii) examine changes in brain activity to cues at different stages of PD. This ongoing single-site study uses an exploratory observational design, with laboratory application of cues for gait deficit. A total of 80 people with PD who meet the inclusion criteria will be enrolled. Participants are split into groups dependent on their disease stage (classified with the Hoehn and Yahr (H&Y) scale); n = 20 H&YI; n = 30 H&YII; n = 30 H&YIII. Within the H&Y stage II and III groups, we will also ensure recruitment of a sub-group of 15 individuals with FOG within each group. Participants perform walking tasks under several conditions: baseline walking without cues; randomized cued walking conditions [internal and external (visual, auditory and tactile) cues]. A combined functional near-infrared spectroscopy and electroencephalography system quantifies cortical brain activity while walking. Inertial sensors are used to assess gait. Primary outcome measures are cue-related changes in cortical brain activity while walking, including the relative change in cortical HbO2 and the power spectral densities at alpha (8-13Hz), beta (13-30Hz), delta (0.5-4Hz), theta (4-8Hz) and gamma (30-40Hz) frequency bandwidths. Secondary outcome measures are cue-related changes in spatiotemporal gait characteristics. Findings will enhance our understanding about the cortical responses to different cueing strategies and how they are influenced by PD progression and FOG status. This trial is registered at clinicaltrials.gov (NCT04863560; April 28, 2021, https://clinicaltrials.gov/ct2/show/NCT04863560).

Exploring the feasibility of technological visuo-cognitive training in Parkinson's: Study protocol for a pilot randomised controlled trial.

Visual and cognitive dysfunction are common in Parkinson's disease and relate to balance and gait impairment, as well as increased falls risk and reduced quality of life. Vision and cognition are interrelated (termed visuo-cognition) which makes intervention complex in people with Parkinson's (PwP). Non-pharmacological interventions for visuo-cognitive deficits are possible with modern technology, such as combined mobile applications and stroboscopic glasses, but evidence for their effectiveness in PwP is lacking. We aim to investigate whether technological visuo-cognitive training (TVT) can improve visuo-cognitive function in PwP. We will use a parallel group randomised controlled trial to evaluate the feasibility and acceptability of TVT versus standard care in PwP. Forty PwP who meet our inclusion criteria will be randomly assigned to one of two visuo-cognitive training interventions. Both interventions will be carried out by a qualified physiotherapist in participants own homes (1-hour sessions, twice a week, for 4 weeks). Outcome measures will be assessed on anti-parkinsonian medication at baseline and at the end of the 4-week intervention. Feasibility of the TVT intervention will be assessed in relation to safety and acceptability of the technological intervention, compliance and adherence to the intervention and usability of equipment in participants homes. Additionally, semi structured interviews will be conducted to explore participants' experience of the technology. Exploratory efficacy outcomes will include change in visual attention measured using the Trail Making Test as well as changes in balance, gait, quality of life, fear of falling and levels of activity. This pilot study will focus on the feasibility and acceptability of TVT in PwP and provide preliminary data to support the design of a larger, multi-centre randomised controlled trial. This trial is registered at isrctn.com (ISRCTN46164906).