Research Design: Telehealth and CBT for Parkinson's Disease Study

This report outlines a research design to investigate the effectiveness of telehealth and online cognitive behavioral therapy (CBT) in managing sleep disturbances, anxiety, and depression in Parkinson's Disease (PD) patients who live far from rehabilitation centers. It includes a case scenario of a 67-year-old PD patient named James, detailing his medical history and current physical and mental health challenges. The report identifies Person, Environment, and Occupation (PEO) factors relevant to James's condition, emphasizing the importance of family support and a conducive home environment. It also provides summaries and critical analyses of two research articles focusing on internet-based CBT interventions for PD patients, highlighting the strengths and limitations of each study. The research design aims to address the gap in accessible mental health support for PD patients through telehealth.

Running head: RESEARCH DESIGN 1
Research Design
(Author’s name)
(Institutional Affiliation)

RESEARCH DESIGN 2
Response to the client
Regarding the occupational therapy discussion on online or telehealth therapy option with
James, first I will request him to come accompanied by the caregiver from the family member,
either his wife or one of his children. This is due to his current body condition as his muscular
and physical body has not enough stamina. During the discussion, I will welcome James politely,
introduce myself and ask about his current condition. This will help in determining the best
options and setting goals for the therapy. After familiarizing with James and his caregiver, I will
then explain to him what is online occupational therapy, and why it is important for him. Online
and telehealth therapy is a type of psychological therapy where patients and the therapist will be
operating through a computer and a telephone to convey healthy education therapy and give
advice on interventions and appropriate ways to cope with either anxiety, depression or sleeping
symptoms while the patient is at home.
From his current symptoms, James cannot be able to perform many tasks and thus he will
need to start with performing activities that he can and those that prevent risks for falling. Other
than that, James needs to learn what kind of activities he will be doing and the need for self-
management together with his caregiver. I will teach James how to use the online internet base
and provide a telephone number in case of an emergency. The program will include daily
physiotherapy updates, encouragement quotes, and relevant interventions such as meditation and
standards sleep hygiene. I will explain the expectations James is required to do in his daily
activities setting priorities and respect to possible choices he made. In relevant to his current
body executive functions, I will encourage him to believe in himself in order to boost his esteem
that it is not too late to give up.
Research Question

RESEARCH DESIGN 3
How can telehealth and online cognitive behavior therapy be used in the management of lack of
sleep anxiety, and depression in patients with PD staying at longer distances from the mental
health rehabilitation center?
Person, environment and occupation factors
Person
James, 67 years old suffering from PD and have a previous health history of postural
hypertension gout and angina. James has both, mental, and physiological problems. Physically,
he might be having a head injury due to a fall brought by postural hypotension nine days ago.
Other than that, from the basic assessment tests, James is obviously having increased postural
instability, fewer arms, cannot stand properly, increase fatigue, dysphagia, plus limited clarity in
his speech. These factors are contributing to his other personal problems like difficulties in
walking and inability to perform daily activities such as bathing, toileting, and dressing.
Environment
James is not comfortable in the rehabilitation environment and it seems to have
aggravated his anxiety and depression symptoms. James needs to go home in order to stay with
his family and work on woodwork. Other than that, he does not feel okay due to the fact that he
cannot do ADLs on his own. However, he is surrounded by supporting staff who are helping
him in his daily activities. His family especially his wife is fully supportive. Other environmental
factors include age and sex. Parkinson disease is more prevalence in aged male patients over 60
years(Parkinson’s Foundation, 2019). Other than that, the presence of head injury after a fall acts
as an aggravating factor. A comprehensive assessment of home surroundings will be effective to
prevent risks for falls, promote a conducive exercise environment of available tasks and to create
friendly surroundings that minimize risks for anxiety and stress.

RESEARCH DESIGN 4
Occupational
James is currently retired from inventory manager with Telstra from the past two years
where he has been working in the previous 25 years. This means James has been a very hard
working person with intending to care for his family who includes a wife and two children
currently adults. Other than that, he is currently interested in a new woodwork occupation despite
his current situation. To support, his occupational activities such as exercises and daily activity a
self-management care including the help of a caregiver will be appropriate. Such intervention
can be directed through frequent telephone reminders and time regulated activities to avoid
spending more time in therapeutic communication. Due to his levels of stamina, activities such
as assisted walking, and encouragement to perform simple chores and tasks can be helpful until
he regains enough strength. This requires modification of available tasks at home in order to get
the most appropriate and manageable one.
Article One Summary
Kraepelin, M., Svenningsson, P., Lindefors, N., & Kaldo, V. (2015). Internet-based
cognitive behavioral therapy for depression and anxiety in Parkinson's disease - a pilot
study.
The above study was conducted to determines the impacts of Internet Cognitive Behavioral
Therapy (ICBT) for anxiety and depression on patients with Parkinson Disease (PD). The results
of the above article show ICBT is a successful depression management intervention in PD. This
method of treatment was highly associated with minimizing the Hospital Anxiety Depression
Scale (HADS) to acceptable levels(Kraepelien, Svenningsson, Lindefors, & Kaldo, 2015).

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However, there were no significant results recorded using subscale HADS-A that led to a
decrease in insomnia or anxiety, depressive symptoms as measured by Montgomery Asberg
Depression Rating Scale- Self-rating version (MADRS-S), and any non-motor
symptom(Kraepelien et al., 2015). In addition, most of the individuals were very inactive of
which they at least completed only three assignments per person and the average amount of
treatment evaluation form received by the therapist was only eight(Kraepelien et al., 2015). The
caregiver engagement into treatment was found to promote CBT. In addition, High initial
problem severity in patients contributed to the premature dropouts from the study as three
participants did not finish the study. Some of the causes of dropouts were that the internet was
difficult to use, and they could have required a simpler way. The study concluded that the
involvement of caregiver could increase the adherence of treatment and prevent future
dropouts(Kraepelien et al., 2015). In addition, a more active therapist who keenly follows up the,
patient could also lead to greater impacts.
Strength and limitation
One of the major strengths of this article is that it applied a proper internet-based
treatment in PD using the best available evidence which has led to the identification of clinically
significant practice(Polit & Beck, 2012). Although the sample population was small the methods
of interventions were consistent demonstrating high levels of validity and reliability(Polit &
Beck, 2013). For instance, the author has demonstrated how the interview was done using
questionnaires measuring the individual's satisfaction and interaction and the effects of outcomes
showing high levels of transparency in the research. The adaptation to this method of study was
sufficient as there were low degrees of satisfaction and dropouts indicating high levels of
research planning and management.

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However, there are various limitations that are being exhibited in the research. First, the
sample size used was too small to provide justifiable results that can be practiced in a real
therapy scenario. With such a study population, there is a lack of sufficient rigid information and
thus it is difficult to conclude the effectiveness of the treatment(Levin & Chang, 2014).
Evidence-based intervention is usually based on the research results conducted in larger and
diverse populations(Coolican, 2018). The study does not provide such evidence since sample
selection had a lot of bias in terms of age distribution and, gender and race. Looking at the study,
you cannot understand study location, ethics used, and specific type of individuals recruited. PD
is normally influenced by race, genetics and environmental factors which were not considered
during the research,
In addition, the researcher decided to use tests such as MADRS-S which had no
significant effects on the results and HADS-D were impacted by conditions of the patients. This
shows that the choice of use of appropriate statistical tests was not observed. Other than that, the
study contains a lot of bias regarding the study interventions thus affecting the findings(Goodwin
et al., 2015). For instance, one of the recruits was treated by the therapist which lead to bias of
the results and all individuals were recruited by one researcher and thus sample may not
represent a whole population as the degree of monitoring are not well reordered and may differ
from one therapist to another(Goodwin et al., 2015). Other than that, the research design failed
to include time point and thus improvement and monitoring of patients could lead to bias.
Article two summary
Patel, S., Ojo, O., Genc, G., Oravivattanakul, S., Huo, Y., Rasameesoraj, T., … Fernandez,
H. H. (2017). A Computerized Cognitive behavioral therapy Randomized, Controlled, pilot
trial for insomnia in Parkinson Disease (ACCORD-PD).

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The above article research was conducted to compare the effectiveness of web-based CBT-1
to standard recommendations for insomnia in PD patients. This study demonstrated that,
although there was no major disparity in difficulty in sleeping as measures by Insomnia Severity
Index (ISI), in ITT analysis, possibly because there were high dropouts in computer cognitive
behavioral therapy (CCBT) group, the per-protocol analysis found positive improvements in
reduction of lack of sleepiness in patients who had CCBT than those with normal healthy sleep
education(Patel et al., 2017). At twelve weeks, the subjects who were treated with CCBT
showed positive improvements in the efficacy of the sleep patterns and duration as measured
with ISI. The control group, on the other hand, improved in sleepiness scores using standard
sleep hygiene recommendations. This proves that normal healthy sleep education is crucial in PD
patients with insomnia problems. However, the study concluded that more effective treatment
methods for insomnia are still needed as the extent of improvement measuring using ISI did not
score more than 6(Patel et al., 2017). In addition, the program finds that it is of importance to
include unique needs of patients in the study such as brief afternoon nap, to dresses behavioral
needs, fatigue and modification of sleep.
Strength and limitations
One major strength of the research is shown by the study design used which consisted of
randomized control trials as an effective method since it is usually used to test the usefulness of a
particular intervention comparing to control group(Treasaden, 2013). Other than that, the study
utilized basic ethical considerations at which only the willing participants were recruited and all
signed the informed consent prior to the beginning of the study(WHO, 2016). In addition, the
researche used a commonly neglected method of treatment which had significant results and all
methods of measuring were appropriate. However, this study had a number of limitations. The

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study had a large number of dropouts which reached up to 50% meaning there was either
ineffective monitoring, follow up or participants selection. In addition, despite all patient having
the computers at home, they were not able to use it due to age. Participants recruited had an
average age of 64 years. This study design could work better in a younger population who are
able or understand the uses of a computer in CCBT(Goodwin et al., 2015). This is due to the fact
that aged patients may be having difficulties in computer logging frequency and thus affecting
their adherence. The study design did not have proper monitoring plans as one of the patients
used sleep aids and some had a modification of medicine during the research process which
might have brought bias in the findings

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References
Coolican, H. (2018). Research Methods and Statistics in Psychology. Research Methods and
Statistics in Psychology. https://doi.org/10.4324/9781315201009
Goodwin, V. A., Pickering, R., Ballinger, C., Roberts, H., McIntosh, E., Lamb, S., … Xin, Y.
(2015). A multi-centre, randomised controlled trial of the effectiveness of PDSAFE to
prevent falls among people with Parkinson’s: Study protocol. BMC Neurology.
https://doi.org/10.1186/s12883-015-0332-2
Kraepelien, M., Svenningsson, P., Lindefors, N., & Kaldo, V. (2015). Internet-based cognitive
behavioral therapy for depression and anxiety in parkinson’s disease - a pilot study. Internet
Interventions. https://doi.org/10.1016/j.invent.2014.11.006
Levin, R. F., & Chang, A. (2014). Tactics for teaching evidenced-based practice: Determining
the level of evidence of a study. Worldviews on Evidence-Based Nursing, 11(1), 75–78.
https://doi.org/10.1111/wvn.12023
Parkinson’s Foundation. (2019). Better Lives. Together. Retrieved May 28, 2019, from
https://parkinson.org/Understanding-Parkinsons/Causes/Environmental-Factors
Patel, S., Ojo, O., Genc, G., Oravivattanakul, S., Huo, Y., Rasameesoraj, T., … Fernandez, H. H.
(2017). A Computerized Cognitive behavioral therapy Randomized, Controlled, pilot trial
for insomnia in Parkinson Disease (ACCORD-PD). Journal of Clinical Movement
Disorders. https://doi.org/10.1186/s40734-017-0062-2
Polit, D. F., & Beck, C. T. (2012). Nursing Research: Principles and Methods. Nursing research
Principles and Methods.
Polit, D. F., & Beck, C. T. (2013). Nursing Research; Principles and Methods. Journal of
Chemical Information and Modeling (Vol. 53).

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https://doi.org/10.1017/CBO9781107415324.004
Treasaden, I. (2013). Research methods and statistics. In Revision MCQs and EMIs for the
MRCPsych. https://doi.org/10.1201/b13482-6
WHO. (2016). Ethical standards and procedures for research with human beings. World Health
Organization.

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Appendixes
Appendix A. Appendix two Critical Review form for research article one
CITATION IN APA
Kraepelien, M., Svenningsson, P., Lindefors, N., & Kaldo, V.
(2015). Internet-based cognitive behavioral therapy for
depression and anxiety in Parkinson's disease - a pilot study.
Internet Interventions.
https://doi.org/10.1016/j.invent.2014.11.006
STUDY PURPOSE The primary objective of this study was to determine the effectiveness
of internet-based cognitive behavioral therapy for depression and
anxiety in Parkinson Disease. This answers the research objectives in
essence that it provides the online based strategies that can be used to
manage depression and anxiety in PD.
LITERATURE The research has reviewed the background of the literature relevant to
the study including cited work of previous studies. The literature
suggests that several studies have proved there are new different CBT
that can be used in the management of anxiety and depression
symptoms in PD in order to minimize cost and increase access to
treatment. This includes internet, telephone, and books. Internet-based
CBT has been used in managing various mental health disorders such
as depression in epilepsy. However, the gap exists for the research as
knowledge for the management of anxiety and depression in PD is not
available.
DESIGN This study applied case-control design since there was no control
group. This type of design was used to provide descriptive data about
the relationship between ICBT and therapeutic management of anxiety
and depression in PD.
APPROPRIATENESS
OF THE STUDY
DESIGN
The question the research seeks to answer is fully formulated from the
literature and the gaps that exist. For a pilot study, a case-control
design was appropriate. Case-control designs are normally used where
the researcher seeks to explore different alternatives as the outcomes
are still not understood yet. However, the study does not observe
ethical considerations fully since the author does not explain whether
the recruits sign informed consent.
BIAS There was no sample selection bias as all volunteered to be part of the
participants. However, the participants included aged individuals of
which the population was not well presented. There was no

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measurement bias as all outcome measures were used appropriate
methods. In addition, all intervention applied were appropriate and
strategic. However, different patients had various specific related
problems and thus could have affected the results.
SAMPLE The study included a sample of 12 participants at which all had a
previously diagnosed PD, mild to moderate anxiety and depression
symptoms and a subscale of anxiety and depression of greater than 7.
All individuals were close- examined for recruitment but no consent
form signing is mentioned.
OUTCOMES The primary outcome measure for depression and anxiety was
determined through the HADS scale whereas the secondary measure
was evaluated by MADRS-S. In addition, participants involvement
and therapist activity were measured using a couple of text messages
sent to the researcher and the number of modules they have covered.
Other than that, the Client Satisfaction Questionnaire was used to
assess post-management objective evaluation and patient satisfaction.
HADS Scale
The MDRS-S
-The extent of outcomes was
measured using 7 independent
subscales each containing seven
items
-The MDRS-S score range
between 0-54 as measured using
the Insomnia Severity Index (ISI)
INTERVENTION The interventions included;
The initial interview which determined intervention choice and
treatment goal.
ICBT program for 12 weeks which included interactive forms,
educative texts, and practical exercises.
In addition, the maximum modules were targeted at 11 and more
illustrations and pictures were used to meet the patients needs with
lower executive functions.

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RESULTS The findings of the research show that ICBT can be a successful
method of depression symptoms treatment in PD. There are no
justifiable results recorded using subscale HADS-A that led to a
decrease in insomnia or anxiety, depressive symptoms as measured by
Montgomery Asberg Depression Rating Scale- Self-rating version
(MADRS-S), and any non-motor symptom.
Three patients drop out prematurely
Some of the causes of dropouts were that the internet was difficult to
use, and they could have required a simpler way.
CONCLUSIONS
AND
IMPLICATIONS
The study concluded that ICBT is significant in the management of
depression and anxiety in PD. However, more studies should be
performed in longer durations of time and frequent follow up to prove
efficacy.

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Appendix two Critical Review form for article two
CITATION IN APA
Patel, S., Ojo, O., Genc, G., Oravivattanakul, S., Huo, Y.,
Rasameesoraj, T., … Fernandez, H. H. (2017). A
Computerized Cognitive behavioral therapy Randomized,
Controlled, pilot trial for insomnia in Parkinson Disease
(ACCORD-PD). Journal of Clinical Movement Disorders.
https://doi.org/10.1186/s40734-017-0062-2
STUDY PURPOSE This study was conducted to check whether the computer cognitive
behavioral therapy program of six weeks was appropriate to manage
the lack of sleep in PD patients. The research will facilitate in
answering the question as it provides an online-based program for the
management of sleepiness in PD.
LITERATURE The literature from the article provides enough background and
research that were done prior to this study. CBT has been used in long
term management of lack of sleep PD. However, the extensive use of
CBT has been difficult because of a limited number of qualified health
care providers and high cost. For that reason, a gap in the research
exists to provide a computer-based CBT that is more convenient.
DESIGN This study applies random control trials study design as it was set to
check the impacts of computer-based CBT in long-distance
individuals with problems in sleeping in PD.
APPROPRIATENESS
OF THE STUDY
DESIGN
Since the study was a controlled trial, the random control trial design
was appropriate for the study. This is because the researcher intended
to determine the effectiveness of a given management method as
compared to the control group. All measurements of outcomes were
well explained and appropriate for the research. In addition, the aim of
the research was well formulated from the literature creating a gap that
led to research. Other than that, the author did observe all ethical
considerations. Participants were presented with informed consent at
which they signed before begging the study.
BIAS Regarding the sample selection, there was no bias as all participants
selected represented a wide range of age. All method of measurement
was direct and straight showing high levels of outcome measures. The
methods used in interventions were well monitored and discrete in
both groups. However, some participants used other medication and
pills for sleep thus the outcomes could have been affected. Other than

RESEARCH DESIGN 15
that, 50% of individuals dropout thus the outcome measures in both
group could have brought bias.
SAMPLE The study includes a sample population of 28 participants in a six
randomized control trial. All participants were of thirty-five to eighty-
five years, previously detected with PD by a Movement Disorders
Neurologist and be positively complying with medicine for the past
one month. All patients were presented with the informed consent of
which once signed the participant was given envelops which dictated
their designations.
OUTCOMES The outcomes measure was the improvement of insomnia in PD as
measured by Epworth Sleepiness Scale, Pittsburgh Insomnia Rating
Scale, Insomnia Severity Index, Fatigue Severity Scale, Unified
Parkinson Disease Rating Scale, Patient Health Questionnaire and
Parkinson Disease Questionnaire.
INTERVENTION All patients were subjected to a six-week CCBT program at which
each individual was given a unique password for the login in the
website.
The therapist used daily email reminders to encourage patients to
complete their daily sleep efficacy and sleep log responses.
Relaxation and mediation strategies were used throughout the program
to promote sleeping and management of stress.
Study persons were also subjected to sleep hygiene and cell phone
reminders.
RESULTS The authors of the research found that, although there was no major
disparity in lack of sleep problems as measures by Insomnia Severity
Index (ISI), in ITT analysis, possibly due to the fact that there were
high dropouts in computer cognitive behavioral therapy (CCBT)
group , the per-protocol analysis found positive improvements in
sleepiness symptoms in patients who had CCBT than those with
normal sleep hygiene education.
At twelve weeks, the subjects who were treated with CCBT showed
positive improvements in sleep efficacy as measured with ISI.
There were also improvements in sleepiness scores when the standard
written sleep hygiene recommendations were used in the control
group.
CONCLUSIONS
AND
IMPLICATIONS
The researcher came to the conclusion that CCBT has a positive
impact on the management of sleep in PD. However, further larger
studies with more monitoring progress and trained personnel are
needed to prove the same.

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