Determinants of exercise behaviour in persons with Parkinson's disease

Integrating deliberate shaking into daily living: a paradoxical exercise for Parkinsonian tremor

PURPOSE

Medication often falls short in controlling tremors in Parkinson's disease. While physical activities suggest potential benefits, current exercise regimes have limitations. This paper explores the concept of deliberate shaking as an intervention to aid exercise uptake and potentially leverage synergies between medication and physical activity. It examines the rationale for and mechanisms of deliberate shaking before exploring its further examination and implementation for tremor rehabilitation.

METHOD

This conceptual article draws on relevant literature using the SANRA guide to explore the potential of deliberate shaking to relieve tremors in Parkinson's disease.

RESULTS

Deliberate shaking is a controlled exercise where an individual consciously initiates and partially surrenders to rhythmic movements while maintaining the ability to stop at will. Integrated into daily activities, this practice may target and stimulate specific muscle groups. It may alleviate tremor through various mechanisms: neurobiological, physiological, and cognitive and psychological. Before implementation, empirical research is needed to assess its feasibility, safety, and effectiveness. Implementation requires assessing eligibility for a shaking prescription, setting personalized goals, providing guidance as needed, and ensuring appropriate safety measures are in place.

CONCLUSIONS

Deliberate shaking is a potential adjunct treatment for Parkinsonian tremor. However, it requires further testing.

Rock Steady Boxing: A qualitative evaluation of a community exercise program for people with Parkinson's disease

PURPOSE

Regular exercise can reduce the symptoms of Parkinson's disease, a common neurodegenerative disorder. The Rock Steady Boxing organization created an exercise program for people with Parkinson's Disease (pwPD) modelled after traditional boxing. The purpose of this study was to better understand the physical function, exercise beliefs, contextual factors, class experiences and outcome perceptions of pwPD participating in Rock Steady Boxing.

MATERIALS AND METHODS

A pragmatic qualitative approach of semi-structured interviews and class observations was supplemented by cross-sectional physical function measures.

RESULTS

Ten study participants were community dwelling adults with Parkinson's Disease, participating in Rock Steady Boxing two to three times a week for an average of 10.6 (6.2) months. Most participants (7/10) had good mobility with Timed Up and Go scores below the 14.8 second average for community dwelling pwPD (7/10) and Parkinson's Disease Questionnaire-39 Mobility Scores < 50% (8/10). Participants (9/10) had good exercise self-efficacy, with average scores on the Short Self-efficacy for Exercise Scale > 3/5. Thematic analysis revealed a history of exercise and strong exercise beliefs positively influenced participation. Rock Steady Boxing provided valued social interactions and offered individualized attention through personalized modifications.

CONCLUSIONS

Instructor enthusiasm, program modifiability and social support drive participation and provide a challenge for differing abilities. RSB is a valued community offering for pwPD.

Factors Associated With Physical Activity and Sedentary Behavior in People With Parkinson Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

The goal of this review was to investigate factors associated with physical activity and sedentary behavior in people with Parkinson disease (PD). The magnitude of these associations was investigated in line with the International Classification of Functioning, Disability and Health components.

METHODS

A systematic literature review was conducted until February 2023, searching four databases (PubMed, EMBASE, Web of Science, and Scopus) for original articles investigating associations with physical activity or sedentary behavior in people with PD. Two independent researchers performed data extraction, and the risk of bias in the included studies was assessed using the Quality in Prognosis Studies tool. Meta-analyses were conducted to determine the magnitude of the associations, and significant regression models from the included studies were described.

RESULTS

Forty-two studies were included. Twenty-one factors associated with overall physical activity were identified. Higher levels of physical activity had a small association with cognition and body mass index and a fair association with 17 factors related to self-efficacy, physical function, mobility, quality of life, age, PD symptoms, and more. Better manual dexterity and functional gait had moderate to good associations with higher levels of physical activity. The regression model with the higher magnitude was composed mostly of contextual factors, except for the body max index. The magnitude of factors associated with physical activity intensity or sedentary behavior could not be identified.

CONCLUSION

Functional gait and manual dexterity were the strongest factors related to physical activity in people with PD. Further investigation is needed to understand the factors associated with physical activity intensity and sedentary behavior.

IMPACT

This study emphasizes the significance of considering contextual factors alongside body function and structure, activity and participation, and the health condition to enhance physical activity improvement during the rehabilitation process. By adopting such a holistic approach, rehabilitation professionals can optimize the overall health and well-being of individuals with Parkinson disease.

Experiences of people living with Parkinson's disease and key stakeholders in dance-based programs: a systematic review and meta-ethnography

PURPOSE

To identify and synthesize qualitative literature on the experiences of participants and key stakeholders in dance programs for people living with Parkinson's disease. Synthesizing the available literature can generate new insights into participant experience to inform current and future programs.

MATERIALS AND METHODS

Qualitative and mixed methods studies were identified via a systematic search of six databases: CINAHL, Web of Science, Scopus, SPORTDiscus, PsycInfo, and MEDLINE. Articles were synthesized using the meta-ethnographic method developed by Noblit and Hare (1988). Key concepts across studies were related via reciprocal translation, ultimately forming a line-of-argument synthesis.

RESULTS

26 articles met the inclusion criteria. Four interrelated, overarching themes were developed: (1) dance communities provide peer support and insight into living with Parkinson's, (2) feeling safe, accepted, and included in the dance experience, (3) overcoming dance-based challenges contributes to sense of achievement, confidence, and connectedness, and (4) dance participation is an opportunity to re-imagine oneself.

CONCLUSION

Participant experience is shaped by the instructor-participant relationship, the social environment of classes, and class difficulty level. In order to support participant experience, classes should be safe, supportive, and have an appropriate challenge-skill balance. These qualities facilitate creative immersion and the potential for personal and collective change.

Socio-Clinical factors associated with Parkinson's disease-related specific self-management behaviours

OBJECTIVE

To test associations between socio-clinical factors, self-management and patient activation among patients with Parkinson's disease (PD), and to explore the use of regression tree to find the cut-off levels of socio-clinical factors which associate with lower or higher self-management behaviours and patient's activation.

METHODS

A cross-sectional study of patients with PD (n = 62) who underwent assessment of their socio-clinical factors including age, gender, cognitive status, comorbidities, disease severity (motor and non-motor symptoms) and social support. The associations of these factors to specific aspects of self-management behaviours including utilization of rehabilitative treatments, physical activity and patient activation were tested.

RESULTS

Most patients did not utilize rehabilitative treatments. Non-motor symptoms and cognitive status were significantly associated with physical activity (R2 = 0.35, F(3, 58) = 10.50, p < 0.001). Non-motor symptoms were significantly associated with patient activation (R2 = 0.30, F(1, 30) = 25.88, p < 0.001). Patients with Mini-Mental State Exam score ≤24 performed less physical activity, relative to those with a higher score. Patients with ≤5 non-motor symptoms showed higher activation relative to those with >5.

CONCLUSION

In PD, disease-specific clinical characteristics overshadow other personal factors as determinants of self-management behaviours. The role of non-motor symptoms in reduced self-management behaviours and activation is highlighted.

Effects of long-term adapted physical training on functional capacity and quality of life in older adults with Parkinson's disease

Background

Parkinson's disease (PD) remains incurable and its prevalence is increasing as the population ages. Although physical activity is considered a therapeutic treatment to slow the progression of the disease, it is considered to be an effective non-pharmacological adjuvant to medication to improve the symptom management.

Methods

The training program was offered for all the participants (N = 50) in three non-consecutive sessions per week for 60 minutes and a total duration of 12 to 16 months. Each session is composed of warming up, adapted boxing training exercises, muscle building and resistance exercises, and returning to calm. For the measurement of physical capacities, the following tests were administered: the Fullerton Advanced Balance Scale (FAB), Timed Up and Go (TUG), and the 30-second chair lift test (TLC30). With regard to quality of life, the Parkinson's Disease Questionnaire of 39 questions (PDQ-39) was used. The participants (age range from 60 to 80 years) were divided following the results of the Parkinson disease severity (Questionnaire Hoehn and Yahr; H&Y) into two groups (H&Y 1-2: mild to moderate symptoms; H&Y 3-4: moderate to severe symptoms).

Objective

The aim of this research was to assess the long-term effects (12 to 16 months) of a community-wide adapted physical program on the physical capacity and quality of life of people with Parkinson disease.

Conclusion

In view of the results, adapted physical training appears to be beneficial for physical capacity and life quality and considered to be an important approch for maintaining the physical and mental capacities and slowing down the proression of neurodegenrative disease.

"There is only one motive … fun." Perspectives of participants and providers of physical exercise for people with Parkinson's disease

PURPOSE

To explore the perspectives of people with Parkinson's disease (PD) and exercise providers regarding facilitating factors, barriers, needs, and demands relating to physical exercise for people with PD.

MATERIALS AND METHODS

Focus group discussions or telephone interviews of 30 people with PD (with or without an active sports history) and 13 providers were conducted and analyzed using structuring content analysis.

RESULTS

Factors facilitating participation in physical exercise included motivation-enhancing elements (enjoyment, group training environment) and providers with sufficient qualifications in PD-specific training demands. Identified barriers were lack of motivation, physical limitations, poor service accessibility, and inadequate matching of intervention groups based on capability or age. Providers found it difficult to design and conduct group trainings for people with PD with varying physical limitations. Having an active sports history before PD-onset was described as generally beneficial, though a competitive mindset could lead to frustration. People with PD reported needing their physicians to provide better education regarding physical exercise.

CONCLUSION

Enjoyment of physical exercise is a key aspect of maintaining physical activity engagement, which should be considered more in research and clinical practice. Developing qualifications for providers could help to broaden and enhance the dissemination of PD-specific exercise approaches. Physicians should be trained to encourage physical exercise.Implications for rehabilitationPhysicians should highlight the benefits and be knowledgeable regarding the availability of physical exercise interventions for people with PD.Additional physical exercise providers should become qualified to work with people with PD.The joyfulness of physical exercise interventions is a key aspect of maintaining physical activity engagement for people with PD.

Exercise Habits in People with Parkinson's: A Multinational Survey

BACKGROUND

Exercise has been demonstrated to result in improvements in physical function, cognition, and quality of life in People with Parkinson's (PwP) but its adoption is variable.

OBJECTIVES

To investigate exercise preferences, levels, influencing factors among a diverse Parkinson's disease (PD) population, to understand exercise adoption patterns and plan informed interventions.

METHODS

A cross-sectional survey collected data through online platforms and paper-based methods. The Exercise Index (ExI) calculated exercise level based on frequency and duration.

RESULTS

Of 2976 PwP, 40.6% exercised regularly, 38.3% occasionally, and 21.2% did not exercise. The overall mean ExI was 18.99 ± 12.37. Factors associated with high exercise levels included exercising in groups (ExI 24-26), weightlifting (ExI 27 (highest)), using muscle-building equipment (ExI 25-26), and exercising at home following an app (ExI 26). A positive trend between ExI and varied exercise groups, locations, types, and equipment was observed. No expected benefit from exercise achieved the lowest ExI (8). Having at least two exercise-promoting factors, a bachelor's degree or higher, receiving exercise advice at initial visits, and aged ≤40 years at PD onset were strong predictors of exercise (adjust OR = 7.814; 6.981; 4.170; 3.565). Falls and "other" most troublesome PD symptoms were negative predictors (aOR = 0.359; 0.466). Barriers to exercise did not predict the odds of exercise.

CONCLUSIONS

The study shows that PwP's exercise behavior is influenced by their exercise belief, age at PD onset, doctor's advice at initial visits, education level, symptoms, and exercise-promoting factors. High exercise levels were associated with certain types of exercises and exercising in groups.

Cognition and Activity of Daily Living Function in people with Parkinson's disease

The ability to perform activities of daily living (ADL) function is a multifaceted construct that reflects functionality in different daily life situations. The loss of ADL function due to cognitive impairment is the core feature for the diagnosis of Parkinson's disease dementia (PDD). In contrast to Alzheimer's disease, ADL impairment in PD can be compromised by various factors, including motor and non-motor aspects. This narrative review summarizes the current state of knowledge on the association of cognition and ADL function in people with PD and introduces the concept of "cognitive ADL" impairment for those problems in everyday life that are associated with cognitive deterioration as their primary cause. Assessment of cognitive ADL impairment is challenging because self-ratings, informant-ratings, and performance-based assessments seldomly differentiate between "cognitive" and "motor" aspects of ADL. ADL function in PD is related to multiple cognitive domains, with attention, executive function, and memory being particularly relevant. Cognitive ADL impairment is characterized by behavioral anomalies such as trial-and-error behavior or task step omissions, and is associated with lower engagement in everyday behaviors, as suggested by physical activity levels and prolonged sedentary behavior. First evidence shows that physical and multi-domain interventions may improve ADL function, in general, but the evidence is confounded by motor aspects. Large multicenter randomized controlled trials with cognitive ADL function as primary outcome are needed to investigate which pharmacological and non-pharmacological interventions can effectively prevent or delay deterioration of cognitive ADL function, and ultimately the progression and conversion to PDD.

MoveONParkinson: developing a personalized motivational solution for Parkinson's disease management

Introduction

Despite the effectiveness of exercise-based interventions on symptom management and disease progression, many people with Parkinson's Disease (PwPD) do not exercise regularly. In line with the ubiquitous use of digital health technology, the MoveONParkinson digital solution was developed, comprising a Web Platform and a Mobile App with a Conversational Agent (CA). The interface features were designed based on the principles of Social Cognitive Theory with the goal of fostering behavior change in PwPD for sustained exercise participation and improved disease management.

Methods

Using a mixed methods approach, this study aimed to collect feedback, assess the acceptability of the Mobile App and the Web Platform, and evaluate the usability of the latter. Quantitative data, which included questionnaire responses and the System Usability Scale (SUS) scores, were analyzed using descriptive statistics, heatmaps, and correlation matrices. Qualitative data, comprising semi-structured and thinking-aloud interview transcripts, were subjected to an inductive thematic analysis. A total of 28 participants were involved in the study, comprising 20 physiotherapists (average age: 34.50 ± 10.4), and eight PwPD (average age: 65.75 ± 8.63; mean Hoehn & Yahr: 2.0 (± 0.76)).

Results

Three main themes emerged from the thematic analysis of the interviews, namely: Self-management (Theme 1), User Engagement (Theme 2), and Recommendations (Theme 3). The assessment of the Mobile App and the CA (mean score: 4.42/5.0 ± 0.79) suggests that PwPD were able to navigate this interface without notable difficulties. The mean SUS score of 79.50 (± 12.40%) with a 95% confidence interval ranging from 73.70 to 85.30, reveal good usability.

Discussion

These findings indicate a high level of acceptability of the MoveONParkinson digital solution, serving as a foundation for assessing its impact on exercise engagement and, subsequently, its influence on symptom management and quality of life of PwPD.

Exercise for People with Parkinson's Disease: Updates and Future Considerations

Parkinson's disease (PD) is now the world's fastest-growing neurological disorder with rapidly rising prevalence and increasing demand for effective health services. Recent research has focused on the importance of early diagnosis and proactive management of physical function. Accumulating evidence indicates that reduced physical activity levels and mild pre-clinical disability are present in many people prior to a clinical diagnosis, perhaps developing over years. Early referral to a physiotherapist at the time of diagnosis is now recommended in global guidelines. Multiple forms of exercise have been found to have benefits in early and mid-stage disease across a range of motor and non-motor symptoms. Evidence from longitudinal studies confirms that disability is delayed when regular exercise is sustained over long periods. Exercise is now recognized as an essential component of treatment, in combination with medical therapies. Contemporary physiotherapy interventions now combine health behavior change techniques with physical exercise to promote the development of long-term exercise adherence. Advances in technology and digital health have progressed quickly and now offer opportunities for remote assessment and monitoring, remote exercise supervision, and support adherence through feedback and motivational strategies. Recent biomedical discoveries forecast improved earlier and more accurate diagnosis of PD, allowing opportunities for earlier interventions. Current research in progress will provide important insights into the dose and intensity of aerobic exercise in PD. Physiotherapists have important roles in advocacy and education in conjunction with care delivery to support access to evidence-based care for all people with PD.

Comparing the effects of dual-task training and single-task training on walking, balance and cognitive functions in individuals with Parkinson's disease: A systematic review

BACKGROUND

This systematic review aimed to examine whether dual-task (DT) training was superior to single-task (ST) training in improving DT walking, balance and cognitive functions for individuals with Parkinson's disease (PD).

METHODS

Literature search was performed in the following electronic databases: PubMed, the Cochrane Library, Web of Science, and Metstr covering inception to May 10, 2023. And in order to facilitate comparison across trials, we calculated the effect size (Hedges' g) of gait, balance, cognitive, and other parameters under both ST and DT conditions, using the mean change score and standard deviation (SD) of change score of the experimental and control groups. Randomized controlled trials that examined the effects of DT motor and cognitive training in individuals with Parkinson's disease were included for this systematic review.

RESULTS

A total of 214 participants recruited from six articles (actually five trials) were involved in this review. In terms of walking ability, only double support time and stride time variability showed significant between-group difference (Hedges' g = 0.34, 0.18, respectively). Compared to ST training group, DT training group had a more improvement effect in laboratory balance measurement (Hedges' g = 0.18, 1.25), but no significant improvement in clinical balance measurement. No significant between-group differences were observed, thus its training effect on cognitive function was inconclusive.

CONCLUSIONS

The DT training failed to achieve promising results better than ST training in improving DT walking and balance functions for individuals with PD. Any firm conclusion cannot be drawn at present, due to the limited number of eligible publications. Larger sample size and high-quality studies are needed to investigate the effectiveness of DT training in individuals with PD.

A backward cycling programme for people with Parkinson's disease: a feasibility and preliminary results study

OBJECTIVE

To assess the feasibility of backward cycling for people with Parkinson's disease. Secondary objectives were to assess changes in gait and balance following a 6-week program.

DESIGN

A single-group prospective pre-test, post-test study with 1-month follow-up.

SUBJECTS/PATIENTS

Twenty-six people with Parkinson's disease (mean age: 69 (7.74) years, gender: 83% males, time since diagnosis: 6 (4.44) years).

METHODS

Participants pedaled backward on a stationary bicycle for 30 minutes at moderate intensity twice a week for 6 weeks. Feasibility was assessed by acceptability, suitability, and burden. Data collected at pre- and post-intervention with 1-month follow-up included backward stepping response variables, forward/backward gait variables, Mini-Balance Evaluation Systems Test (MBT), and 6 Minute Walk Test.

RESULTS

There was a high retention rate (95.8%) and adherence rate (100%) with one adverse event and minimal burden. Significant improvements were seen in step count and excursion distance during backward stepping responses, forward and backward gait velocity, forward step length, and the Mini-BESTest.

CONCLUSION

Backward cycling was a feasible intervention for people with Parkinson's disease, demonstrating low burden with high retention and adherence rates, and it is a safe exercise with the potential for benefits in gait and balance variables.

Vertical locomotion improves horizontal locomotion: effects of climbing on gait and other mobility aspects in Parkinson's disease. A secondary analysis from a randomized controlled trial

BACKGROUND

In the Climb Up! Head Up! trial, we showed that sport climbing reduces bradykinesia, tremor, and rigidity in mildly to moderately affected participants with Parkinson's disease. This secondary analysis aimed to evaluate the effects of sport climbing on gait and functional mobility in this cohort.

METHODS

Climb Up! Head Up! was a 1:1 randomized controlled trial. Forty-eight PD participants (Hoehn and Yahr stage 2-3) either participated in a 12-week, 90-min-per-week sport climbing course (intervention group) or were engaged in regular unsupervised physical activity (control group). Relevant outcome measures for this analysis were extracted from six inertial measurement units placed on the extremities, chest, and lower back, that were worn during supervised gait and functional mobility assessments before and after the intervention. Assessments included normal and fast walking, dual-tasking walking, Timed Up and Go test, Instrumented Stand and Walk test, and Five Times Sit to Stand test.

RESULTS

Compared to baseline, climbing improved gait speed during normal walking by 0.09 m/s (p = 0.005) and during fast walking by 0.1 m/s. Climbing also reduced the time spent in the stance phase during fast walking by 0.03 s. Climbing improved the walking speed in the 7-m- Timed Up and Go test by 0.1 m/s (p < 0.001) and the turning speed by 0.39 s (p = 0.052), the speed in the Instrumented Stand and Walk test by 0.1 m/s (p < 0.001), and the speed in the Five Times Sit to Stand test by 2.5 s (p = 0.014). There was no effect of sport climbing on gait speed or gait variables during dual-task walking.

CONCLUSIONS

Sport climbing improves gait speed during normal and fast walking, as well as functional mobility in people with Parkinson's disease. Trial registration This study was registered within the U.S. National Library of Medicine (No: NCT04569981, date of registration September 30th, 2020).

Parkinson's disease physical therapy services during COVID-19: A phenomenological study

OBJECTIVES

Parkinson's disease (PD) is the most rapidly increasing movement disorder globally. Physical therapies improve the motor and non-motor symptoms of PD. During the COVID-19 pandemic, telehealth was the primary method of physical therapy service adaptation in response to restrictions preventing in-person therapy attendance. This study explores the perspectives of people with PD and their therapists who experienced physical therapy service delivery before and during the COVID-19 pandemic in Melbourne, Australia.

METHODS

A phenomenological study that purposively recruited patients and therapists from a movement disorders service at an outer metropolitan rehabilitation hospital. Participants completed in-depth interviews, and data were analysed using reflexive thematic analysis.

RESULTS

Ten people with PD and five therapists completed interviews. Six themes were identified: patients value access to therapy, a key mechanism is trust, an opportunity to empower patients, ticking boxes for telehealth, contrasting experiences of telehealth and something is better than nothing.

CONCLUSIONS

This study explored the experiences of people with PD and their therapists by contrasting their prepandemic and in-pandemic experiences. People with PD valued telehealth access during the pandemic, but extra support was initially required to use telehealth successfully. Empowering aspects of telehealth included patients learning new skills and self-management strategies from telehealth interactions with therapists. Therapists at this health service were motivated to continue with telehealth beyond the pandemic. Despite finding it challenging initially, they were surprised by how well people with PD managed telehealth using locally developed procedures based on clinical judgement and staff training that addressed patient safety while supporting people with PD to utilise telehealth.

Community Exercise: A New Tool for Personalized Parkinson’s Care or Just an Addition to Formal Care?

Physiotherapy and exercise are associated with motor and non-motor benefits in Parkinson’s disease (PD). Community exercise programs may increase ongoing exercise participation and help people with Parkinson’s disease actively participate in their health management. But there is still limited knowledge about these programs regarding their benefits, safety, implications over the long-term, and effective implementation. These questions could hold relevant clinical implications. In this perspective article, we identify the current challenges and reflect upon potential solutions to help community exercise to be implemented as an additional anchor to personalize management models for Parkinson’s disease.

Six-Month Community-Based Brisk Walking and Balance Exercise Alleviates Motor Symptoms and Promotes Functions in People with Parkinson's Disease: A Randomized Controlled Trial

BACKGROUND

In Parkinson's disease (PD), sustained aerobic exercise is a promising therapy in delaying motor disability. Brisk walking is a moderate intensity aerobic training, which could be translated to community practice at low cost, but its effects on motor symptoms remains unclear.

OBJECTIVE

To determine the effectiveness of a six-month brisk walking and balance program in alleviating motor symptoms, and promoting functional, gait, and balance performance in people with PD.

METHODS

Seventy individuals with mild to moderate PD were randomly assigned to a brisk walking (BW) group or an active control (CON) group. BW group received ten 90-minute supervised brisk walking and balance exercise for six months (weeks 1-6: once/week, weeks 7-26: once/month). CON group received upper limb training. Both groups performed 2-3 self-practice sessions weekly. Primary outcome was Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score. Secondary outcomes were fast gait speed (FGS), timed-up-and-go (TUG) time, six-minute walk distance (6MWD), and Mini-Balance Evaluation Systems Test (Mini-BEST) score.

RESULTS

Sixty-four participants (33 BW/31 CON) completed training. BW group showed greater significant decreases from baseline than CON group in MDS-UPDRS motor score after six weeks (-5.5 vs -1.6, p < 0.001) and 6 months (-6.0 vs -1.4, p < 0.001) of training. BW group also showed greater significant improvement from the baseline than CON group for TUG time, FGS, 6MWD, and mini-BEST score (all p < 0.05).

CONCLUSION

The six-month brisk walking and balance program alleviates motor symptoms, promotes functional and gait performance, walking capacity, and dynamic balance in people with mild to moderate PD.

Towards Symptom-Specific Intervention Recommendation Systems

BACKGROUND

Mobile devices and their capabilities (e.g., device sensors and human-device interactions) are increasingly being considered for use in clinical assessments and disease monitoring due to their ability to provide objective, repeatable, and more accurate measures of neurocognitive performance. These mobile-based assessments also provide a foundation for the design of intervention recommendations.

OBJECTIVE

The purpose of this work was to assess the benefits of various physical intervention programs as they relate to Parkinson's disease (PD), its symptoms, and stages (Hoehn and Yahr (H&Y) Stages 1-5).

METHODS

Ninety-five participants (n = 70 PD; n = 25 control) completed 14 tablet-based neurocognitive functional tests (e.g., motor, memory, speech, executive, and multi-function) and standardized health questionnaires. 208 symptom-specific digital features were normalized to assess the benefits of various physical intervention programs (e.g., aerobic activity, non-contact boxing, functional strength, and yoga) for individuals with PD. While previous studies have shown that physical interventions improve both motor and non-motor PD symptoms, this paper expands on previous works by mapping symptom-specific neurocognitive functionalities to specific physical intervention programs across stages of PD.

RESULTS

For early-stage PD (e.g., H&Y Stages 1 & 2), functional strength activities provided the largest overall significant delta improvement (Δ= 0.1883; p = 0.0265), whereas aerobic activity provided the largest overall significant delta improvement (Δ= 0.2700; p = 0.0364) for advanced stages of PD (e.g., H&Y Stages 3-5).

CONCLUSIONS

As mobile-based digital health technology allows for the collection of larger, labeled, objective datasets, new ways to analyze and interpret patterns in this data emerge which can ultimately lead to new personalized medicine programs.

A Systematic Review on Physical Health Education Interventions for People with Parkinson's Disease: Content, Impact, and Implementation Considerations Across the Parkinson's Trajectory

BACKGROUND

Educational interventions promoting the role of physical activity (PA) aim to address knowledge, poor exercise self-efficacy, and low outcome expectations, which are well-researched barriers to PA participation in healthy and in people with chronic conditions. However, little is known about the effectiveness of educational interventions in addressing these barriers in people with Parkinson's (PwP).

OBJECTIVE

To examine the content of education interventions that promote PA behavior in PwP, and to assess their effectiveness on physical and psychosocial outcomes.

METHODS

An electronic search (12/2021) of MEDLINE, EMBASE, CINAHL, PubMed PsycINFO, the Web of Science and the Cochrane Library was conducted from 1990 to 2021. Education interventions, alone or combined with other strategies, promoting PA in PwP were included. Quality was assessed using the Johanna Briggs Institute and National Institute of Health quality assessment tools. A narrative synthesis was performed.

RESULTS

Six studies were identified. Five interventions were comprised of education and exercise sessions. Improvement in physical and psychosocial outcomes were suggested but delineating the exact impact of education was impeded due to lack of assessment.

CONCLUSION

Few interventions exist that provide knowledge, and skills promoting PA participation, and fewer are addressed towards newly diagnosed PwP. There is lack of assessment over the effectiveness of education as a tool to facilitate PA participation in PwP. Lack of assessment poses the risk of potentially disregarding effective interventions or adopting ineffective approaches without the evidence. Education interventions can boost PA engagement by increasing factors such as exercise self-efficacy, but further interventions are required to assess this model of relationship.

Motor and Non-motor Symptoms Associated With Exercise Behavior in Parkinson's Disease Patients: Factors Differ Between Patients With and Without Postural Instability

Background: Exercise is an important treatment for Parkinson's disease (PD). Therefore, recognizing determinants of exercise behavior for PD based on disease stage is essential. We sought to find whether the determinants differ based on presence of postural instability (PI), which is indicative of disease stage in PD. Methods: We enrolled patients at Samsung Medical Center from September 2019 to November 2020, who had the ability to perform exercise [modified Hoehn and Yahr (HY) stage ≤ 3]. All the motor and non-motor symptoms were investigated. The exercise of the PD patients was evaluated using the Physical Activity Scale of the Elderly (PASE)-leisure score. We classified patients into PD without PI (HY stage 1 - 2) and PD with PI (HY stage 2.5 - 3) groups. Multivariate linear regression was performed using backward elimination in each group to determine factors associated with PASE-leisure score. Results: A total of 233 patients were enrolled. In the PD without PI group (n = 177), the positive determinant of exercise was Activities-Specific Balance Confidence (ABC) score (β = 0.142, p = 0.032), and the negative determinants were fatigue score (β = -0.228, p = 0.018), female (β = -6.900, p = 0.016) and currently employed status (β = -6.072, p = 0.046). In the PD with PI group (n = 56), the positive determinant was non-motor symptom scale (NMSS) score (β = 0.221, p = 0.017) and disease duration (β = 1.001, p = 0.036), while the negative determinants were UPDRS part 3 score (β = -0.974, p < 0.001), UPDRS part 4 score (β = -2.192, p = 0.002), and age (β = -1.052, p < 0.001). Conclusion: Different motor and non-motor symptoms were associated with the exercise in PD patients with and without PI. When encouraging PD patients to exercise, personalized and different strategies should be applied based on the presence of PI.

The Impact of COVID-19 on Community-Based Exercise Classes for People With Parkinson Disease

OBJECTIVE

he purpose of the study was to determine the impact of novel coronavirus 2019 (COVID-19) restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors.

METHODS

Data were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class ≥1 time/week for ≥3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire, Self-Efficacy for Exercise scale, Schwab-England scale, and Parkinson's Disease Questionnaire 8.

RESULTS

Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and Parkinson's Disease Questionnaire 8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns, and 54% reported leaving home ≤1 time/week. Although 77% of the PD group scored "active" on the Godin Leisure-Time Questionnaire, the mean Self-Efficacy for Exercise Scale score (55 [24]) indicated only moderate exercise self-efficacy, and >50% reported decreased exercise quantity/intensity compared with pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group).

CONCLUSION

During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization.

IMPACT

As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD.

LAY SUMMARY

During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction.

Physical Activity and Perceived Health in People With Parkinson Disease During the First Wave of Covid-19 Pandemic: A Cross-sectional Study From Sweden

BACKGROUND

People with Parkinson disease (PD) are known to be at risk of physical inactivity and may therefore be especially vulnerable to negative health outcomes during the COVID-19 pandemic due to social distancing recommendations.

PURPOSE

To investigate sensor-derived physical activity and perceived health of people with PD during the first wave of the COVID-19 pandemic, as well as the factors associated with these outcomes.

METHODS

Physical activity was measured over 7 days using the Actigraph GT3x accelerometer. Data were collected regarding perceived health status and physical activity habits, as well as rehabilitation attendance during the pandemic. Multiple linear and logistic regression analyses were used to identify factors associated with physical activity and perceived changes in health.

RESULTS

Of 89 participants, a majority (67%) reported a pandemic-related reduction in exercise habits. Women more commonly reported a reduction in scheduled exercise and cancelled rehabilitation than men. Study participants took on average 5876 ± 3180 steps per day. In the multivariate analysis, female gender, being 70 years of age and older, and greater reported mobility problems were associated with being less physically active. A pandemic-induced deterioration in health was reported by 42% and women were 5 times more likely than men to do so (odds ratio: 5.12, 95% confidence interval, 1.87-15.03; P = 0.002).

DISCUSSION AND CONCLUSIONS

Despite a pandemic-related reduction in reported exercise habits and rehabilitation, the participants in this Swedish sample were relatively physically active. However, women were less active at moderate-vigorous levels and were at greater risk of deterioration in perceived health during this time.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A359).

Transcranial direct current stimulation (tDCS) in addition to walking training on walking, mobility, and reduction of falls in Parkinson's disease: study protocol for a randomized clinical trial

BACKGROUND

Transcranial direct current stimulation (tDCS) has the potential to modulate cortical excitability and enhance the effects of walking training in people with Parkinson's disease. This study will examine the efficacy of the addition of tDCS to a task-specific walking training to improve walking and mobility and to reduce falls in people with Parkinson's disease.

METHODS

This is a two-arm, prospectively registered, randomized trial with concealed allocation, blinded assessors, participants and therapists, and intention-to-treat analysis. Twenty-four individuals with Parkinson's disease, categorized as slow or intermediate walkers (walking speeds ≤ 1.0 m/s), will be recruited. The experimental group will undertake a 30-min walking training associated with tDCS, for 4 weeks. The control group will undertake the same walking training, but with sham-tDCS. The primary outcome will be comfortable walking speed. Secondary outcomes will include walking step length, walking cadence, walking confidence, mobility, freezing of gait, fear of falling, and falls. Outcomes will be collected by a researcher blinded to group allocation at baseline (week 0), after intervention (week 4), and 1 month beyond intervention (week 8).

DISCUSSION

tDCS associated with walking training may help improve walking of slow and intermediate walkers with Parkinson's disease. If walking is enhanced, the benefits may be accompanied by better mobility and reduced fear of falling, and individuals may experience greater free-living physical activity at home and in the community.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) RBR-6bvnx6 . Registered on September 23, 2019.

Negative Effects of COVID-19 Stay-at-Home Mandates on Physical Intervention Outcomes: A Preliminary Study

BACKGROUND

Due to the COVID-19 pandemic, beneficial physical intervention classes for individuals with Parkinson's disease (PD) were cancelled.

OBJECTIVE

To understand effects of the COVID-19 stay-at-home mandate and the inability to participate in recommended and structured physical interventions as a consequence of these mandates, specifically designed mobile assessments were used that collected both self-reporting information and objective task-based metrics of neurocognitive functions to assess symptom changes for individuals with PD.

METHODS

Self-reporting questionnaires focusing on overall quality of life (e.g., when individuals typically feel at their best, changes in activity levels, and symptom progression) were given to all individuals (n = 28). In addition, mobile-based neurocognitive assessments were administered to a subset of the population (n = 8) to quantitatively assess changes due to COVID-19 restrictions.

RESULTS

The highest self-reported factors in which individuals denoted feeling their best were after exercise (67.86%) and being in a comfortable and supportive environment (60.71%). Objective measures found overall duration of physical activity during the stay-at-home mandate decreased significantly (p = 0.022). With the lack of overall activity, 82.14%of individuals self-reported having at least one symptom that worsened moderately or higher. Further testing, using mobile-based assessments, showed average completion times of functional tasks increased, taking about 2.1 times longer, while accuracy metrics showed overall degradation.

CONCLUSION

Although the COVID-19 stay-at-home mandate was intended to help protect individuals at high risk from coming into contact with the virus, it also prevented individuals from receiving recommended supervised exercise interventions resulting in significant negative effects in social well-being and across motor and speech neurocognitive tasks for individuals with PD.

Community aquatic therapy for Parkinson's disease: an international qualitative study

PURPOSE

To explore the opinions of people living with Parkinson's disease about access to and participation in community aquatic therapy.

METHODS

Focus groups and individual interviews were conducted with people living with Parkinson's disease in Ireland (n = 24) and Australia (n = 10). All discussions were audio-recorded, transcribed verbatim, and thematically analysed.

RESULTS

Four main themes were identified. Primarily, participants were optimistic about their reasons for choosing aquatic therapy and found it beneficial to their health and well-being. Optimal components of aquatic therapy identified were access to individually tailored aquatic programs, completed as a minimum once a week, at a moderate to high-intensity level, and guided by a credentialed instructor. Fear was a significant barrier for a small proportion of participants and was linked to water competence, past experiences, and fall risk associated with the aquatic environment. Participants identified a strong need for education and increased awareness about aquatic therapy benefits to promote greater engagement.

CONCLUSION

Aquatic therapy is a popular exercise choice for people with Parkinson's disease, especially in the early to middle disease stages. Considering the views of people living with Parkinson's disease can aid the design and implementation of interventions and future aquatic research internationally.Implications for RehabilitationAquatic therapy is emerging as an effective physiotherapy approach for managing motor and non-motor symptoms in Parkinson's disease.Little is known regarding community-based aquatic therapy programs from the perspectives of people living with Parkinson's disease internationally.People with Parkinson's disease may benefit from timely information about the unique benefits, prerequisites, and local aquatic therapy facilities to promote greater uptake of aquatic programs.Tailored aquatic therapy interventions delivered within a group setting by a credentialed healthcare professional may increase long-term adherence.

Predictors of physical activity levels in individuals with Parkinson's disease: a cross-sectional study

BACKGROUND

To investigate whether modifiable predictors (depressive symptoms, impairment in behavior and mood, balance impairments, and knee extensor muscle strength) are determinants of the physical activity level in Parkinson's disease.

MATERIALS AND METHODS

A cross-sectional study with individuals diagnosed with idiopathic Parkinson's disease. Regression analysis of the data was used to investigate whether depressive symptoms, impairments in behavior and mood, balance impairments, or dominant knee extensor muscle strength are predictors of physical activity levels in Parkinson's disease.

RESULTS

A total of 50 individuals with mild to moderate Parkinson's disease participated in this study, with a mean age of 67 ± 8 years and 68% male. Balance impairments explained 29% of the variation in the physical activity levels. The explained variance increased to 34% when depressive symptoms were included in the model.

CONCLUSION

Among the predictor variables investigated in our study, only balance impairments and depressive symptoms explained the variance in physical activity levels in individuals with Parkinson's disease.

Current Perspectives on Aerobic Exercise in People with Parkinson's Disease

Parkinson's disease (PD) is a progressive neurological disorder characterized by motor and non-motor symptoms for which only symptomatic treatments exist. Exercise is a widely studied complementary treatment option. Aerobic exercise, defined as continuous movement of the body's large muscles in a rhythmic manner for a sustained period that increases caloric requirements and aims at maintaining or improving physical fitness, appears promising. We performed both a scoping review and a systematic review on the generic and disease-specific health benefits of aerobic exercise for people with PD. We support this by a meta-analysis on the effects on physical fitness (VO2max), motor symptoms (Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor section), and health-related quality of life (39-item Parkinson's disease Questionnaire (PDQ-39)). Aerobic exercise has generic health benefits for people with PD, including a reduced incidence of cardiovascular disease, a lower mortality, and an improved bone health. Additionally, there is level 1 evidence that aerobic exercise improves physical fitness (VO2max) and attenuates motor symptoms (MDS-UPDRS motor section) in the off-medication state, although the long-term effects (beyond 6 months) remain unclear. Dosing the exercise matters: improvements appear to be greater after training at higher intensities compared with moderate intensities. We found insufficient evidence for a beneficial effect of aerobic exercise on health-related quality of life (PDQ-39) and conflicting results regarding non-motor symptoms. Compliance to exercise regimes is challenging for PD patients but may be improved by adding exergaming elements to the training program. Aerobic exercise seems a safe intervention for people with PD, although care must be taken to avoid falls in at-risk individuals. Further studies are needed to establish the long term of aerobic exercise, including a focus on non-motor symptoms and health-related quality of life.

Barriers and Motivators to Engage in Exercise for Persons with Parkinson's Disease

Exercise is increasingly being recognized as a key element in the overall management of persons living with Parkinson's disease (PD) but various (disease-specific) barriers may impede even motivated patients to participate in regular exercise. We aimed to provide a comprehensive review of the various barriers and motivators for exercise in persons with PD. We scrutinized data on compliance-related factors published in cross-sectional studies, randomized controlled trials and reviews. We classified the barriers and motivators to exercise from a patient perspective according to the International Classification of Functioning, Disability and Health. We present an overview of the large range of potential motivators and barriers for exercise in persons with PD. Healthcare professionals should consider a wide and comprehensive range of factors, in order to identify which specific determinants matter most for each individual. Only when persons with PD are adequately motivated in a way that appeals to them and after all person-specific barriers have been tackled, we can begin to expect their long-term adherence to exercise. Such long-term compliance will be essential if exercise is to live up to its expectations, including the hope that prolonged engagement in regular exercise might help to modify the otherwise relentlessly progressive course of PD.