Views of in-person and virtual group exercise before and during the pandemic in people with Parkinson disease

Abstract

Introduction:

Due to coronavirus disease 2019 (COVID-19), many health/wellness programs transitioned from in-person to virtual. This mixed-methods study aims to explore the perceptions of older adults with Parkinson disease (PD) regarding in-person versus virtual-based Parkinson-specific exercise classes (PDEx).

Objective:

Explore experiences, perceptions, and perceived effect of participating in and transitioning from in-person to virtual PDEx in people with Parkinson disease (PwPD).

Design:

Cross-sectional mixed-methods design using an online survey and focus groups.

Setting:

PwPD who participated in an in-person and virtual PDEx (n = 26) were recruited to participate and completed online surveys and focus groups from their home during the COVID-19 pandemic.

Participants:

PwPD who participated in an in-person and virtual PDEx and agreed to participate completed an online survey (n = 16; male = 8; mean age = 74 years) and focus groups (n = 9; male = 4; mean age = 75 years).

Interventions:

N/A

Main Outcome Measures:

Participants completed survey questions and participated in focus groups regarding their perceptions, attitudes, and perceived changes in PD-related symptoms since participating in the PDEx, as well as barriers and facilitators to participating in virtual PDEx.

Results:

Participants felt PDEx was somewhat to very safe and beneficial. In the computer, comfort, and perceptions survey, participants reported perceived improved mobility (63%), balance (75%), and overall health (63%) since participating the PDEx, whereas some participants reported improved mental health (38%). Participants reported minimal difficulty with accessing virtual PDEx. Most participants stated that they would prefer to participate in a combination of in-person and virtual programming. Focus-group participants emphasized that virtual PDEx provided social and emotional support and improved confidence to perform and maintain an exercise regimen.

Conclusion:

PwPD who transitioned from an in-person to a virtual PDEx felt the program was safe, effective, and improved or prevented declines in their mobility and balance. PwPD who transitioned to a virtual PDEx also reported benefits in non-motor symptoms such as social isolation.

INTRODUCTION

Parkinson disease (PD) is a progressive neurodegenerative disorder resulting in numerous motor symptoms^1,2 such as bradykinesia, rigidity, tremors, postural instability, and loss of independence. Non-motor symptoms like cognitive decline, depression, and sleep disturbances can be as debilitating as motor symptoms.³ Along with medications, exercise is an adjunctive intervention to address impairments.^4,5

Because the effects of PD are multidimensional, various forms of exercise are beneficial to address impairments associated with PD.⁵ A systematic review found that resistance training, endurance training, and other exercise modalities (cardiorespiratory fitness, balance, and walking performance) improved strength, gait, and endurance for people with Parkinson disease (PwPD).⁵ Group exercise may be even more beneficial than individualized exercise.^6–8 Raje et al. found that PwPD who exercised in a group reported greater improvements in PD symptoms compared to PwPD who exercised individually—likely because the social aspect of the group was a facilitator to exercising.⁶ States et al. found that group exercise was feasible and effective for PwPD, and resulted in improvements in grip strength and the Six-Minute Walk Test (6MWT) endurance measurement that were retained over the duration of the study.⁷

Due to the coronavirus disease 2019 (COVID-19) pandemic, group exercise classes were either cancelled or transitioned to virtual. COVID-19 can be detrimental mentally and physically for PwPDs.⁸ Song et al. found a decrease in the duration and frequency of exercise performed and that PwPD who exercised less reported worse motor and non-motor symptoms.⁹ These results may be due to COVID-19 mitigations, which resulted in on-site exercise programs being cancelled or delivered virtually (eg, the Engage program).¹⁰ Bek et al. investigated the accessibility and benefits of home-based dance programs for PwPD due to the COVID-19 pandemic through an online survey of 276 PwPD. The authors found that ~95% reported that the home-based program provided some physical (balance and posture) and non-physical (mood and confidence) benefits as well as participants reporting convenience and flexibility with digital programming.¹¹ To our knowledge, there are minimal studies describing the perceptions and experiences of PwPD participating in an in-person PD-specific group exercise program (PDEx) that transitioned to a live, virtual program as a result of a global pandemic. Therefore, this was the focus of our study in the context of the COVID-19 pandemic.

METHODS

Description of exercise program

The PDEx was based on The Parkinson’s Wellness Recovery program (PWR!Moves) to address motor and cognitive impairments associated with PD. PWR!Moves incorporates high-intensity, high-amplitude movements in multiple functional positions repetitively to carry over in the performance of functional tasks independently in a group setting.¹² The classes were led by a PWR!Moves-certified fitness instructor and PWR!Moves-certified physical therapist. The 1-hour-long in-person classes were held two times per week from 20 August, 2019 to 11 March, 2020.

From 11 March, 2020, to 7 April, 2020, classes were not offered due to the COVID-19 pandemic. During this time, a class video was distributed to participants via email and posted on a website. Starting 7 April, 2020, classes were offered live, 2 days per week on Zoom, led by the same instructors. (Please refer to the Supplementary Document 1 for more details about PDEx.)

Study design

This study was approved by the university institutional review board (IRB). This study used a mixed-methods design to explore perceptions and experiences of PwPD regarding in-person PDEx transitioning to virtual due to the COVID-19 pandemic. A survey was used to gather quantitative data. Focus groups were conducted using a semi-structured interview guide and a descriptive phenomenological approach to gain insight into the lived experiences of PwPD who participated in both in-person and virtual PDEx.¹³

Purposive sampling was used. Participants provided their email addresses when registering for the classes. From July 2019 to Feb 2020 (prior to virtual PDEx), the in-person class averaged 32 attendees per month. PwPD may have attended one or more classes during each month. From March 2020 through May 2020, when PDEx transitioned to virtual classes, there was an average of 26 attendees per month. All PwPD who participated in at least one in-person and virtually held PDEx from August 2019 to May 2020 (n = 26), were sent a survey via email. Upon clicking on the survey link, participants were introduced to the informed consent. Participants who completed the survey were also invited to participate in focus groups. The IRB determined that the focus group interview and participant survey did not qualify as human subjects research.

Data collection

Survey

The computer, comfort, and perceptions survey (Survey) collected data on participant characteristics, comfort with technology, knowledge of and referral source to PDEx, and self-reported improvement or decline in symptoms since starting the PDEx (Supplementary Document 1).¹⁴ Due to the cross-sectional nature of this survey, we revised the Parkinson’s Disease Questionnaire (PDQ-39)¹⁵ and Parkinson’s Disease Fatigue Scale (PFS-16)¹⁶ to change scales to ascertain the participants’ perceptions of changes in their PD-related symptoms since they started participating in PDEx, as seen in Fischer et al. (1999).¹⁷ The change scale was rated on a 7-point Likert scale (1: “a great deal worse” to 7: “a great deal better”).¹⁷According to Fisher et al.,¹⁷retrospective patient-reported change is more sensitive and reliable than serial change assessments and more strongly associated with patient satisfaction and actual change. Pilot testing of surveys was completed by two participants to gain insight on survey comprehension and completion time. Surveys were administered between May and July 2020 using the REDCap online, secure data collection tool and took 30 to 45 minutes to complete (Appendix 1 and Appendix 2).

Focus group interviews

Two focus groups (~1 hour each; n = 5 and 4 participants) were conducted in June 2020 by a trained qualitative researcher (H.B.B.). Focus groups were conducted and recorded on Zoom to allow for transcription and audit. All participants were briefed about the purpose of the discussion, that their participation was voluntary, that they could withdraw at any time, and that the focus groups were being recorded. A semi-structured interview guide (Appendix 3) was used to facilitate open, in-depth discussions with PwPD about their perceptions of in-person and virtual PDEx as well as capturing barriers to participating in a PDEx program. If needed, probes were used to encourage elaboration.¹⁸

Data analysis

Survey results and participant characteristics were analyzed using descriptive statistics. Audio recordings of focus groups were transcribed with Descript software (Descript, San Francisco, CA) and then reviewed and edited for accuracy. J.L.V. and H.B.B. analyzed the data using thematic analysis to identify, analyze, and interpret meaning and themes in the data.¹⁹ H.B.B. and J.L.V. first each read all transcripts thoroughly; they were then read a second and third time, and patterns were marked for initial coding. A line-by-line analysis identified important words or phrases, and initial codes were applied. Data were labeled using in vivo codes. A table of initial codes was created, and the most significant or frequent codes were collated and sorted into potential themes. During the final step of analysis, J.L.V. and H.B.B. came to consensus on interrelationships between codes and themes. After themes were identified, data narratives were selected to illustrate, explain, and support them. An audit trail of the raw data, transcripts, data reduction and analysis, and methodological notes was maintained. H.B.B. and J.L.V. agreed that data saturation was attained with the two focus groups, as no new themes emerged from one to the next. The perceptions of the effect and experiences of in-person and virtual PDEx on PwPD emerged through prolonged immersion with the data.²⁰

RESULTS

Participant characteristics

Sixteen community-dwelling individuals who participated in both in-person and virtual PDEx completed the survey (61.5% response rate). Respondents were split evenly between male and female, with an average age of 74 years, and had been diagnosed with PD for an average of 3.3 years. Fifteen participants identified as White and one participant was Black or African American. Nine of the 16 participants who completed the survey completed focus group interviews. Focus group respondents were representative of the survey respondents. Five were female, with an average age of 74.7, and had been diagnosed with PD for an average of 3.3 years. All focus group participants were White.

Transitioning from in-person to virtual

Of the 16 participants who completed the survey, 13 reported regular attendance, although the term “regular attendance” was not defined in the survey (Table 1). Seventy-five percent felt somewhat or very comfortable using technology. Sixty-three percent found transitioning from in-person to virtual PDEx easy or very easy. More than 50% indicated that they preferred both in-person and virtual classes compared to only in-person and only virtual PDEx classes, and 94% responded they were somewhat to very likely to recommend classes to their peers. Despite the transition from in-person to virtual, most participants reported maintenance or improvement in multiple health-specific areas. Specifically, 63% of participants reported improvement in mobility, whereas 31% reported that their mobility was maintained. Seventy-five percent of participants reported improvement in balance, whereas 19% reported that balance was about the same. Thirty-eight percent of participants reported improvement in mental health, whereas 56% reported that their mental health was maintained. Sixty-three percent of participants reported an improvement in overall health since attending either in-person or virtual PDEx classes, whereas 31% reported that their overall health was maintained.

TABLE 1.

Survey results—computer, comfort, and perceptions about the classes

Item	n (%)a (n = 16)
Attend class regularly
No	3 (18.8)
Yes	13 (81.3)
Comfort level with using the computer/Internet at your home
Not at all comfortable	1 (6.3)
Neutral	3 (18.8)
Somewhat comfortable	9 (56.3)
Very comfortable	3 (18.8)
Difficulty transitioning to virtual-based class
Difficult	1 (6.3)
Neutral	5 (31.3)
Easy	3 (18.8)
Very easy	7 (43.8)
Preferred method of class
Both in-person and virtual class offering	9 (56.3)
In-person	3 (18.8)
Virtual	4 (25.0)
Likelihood to recommend class
Neither likely nor unlikely	1 (6.3)
Somewhat likely	2 (12.5)
Very likely	13 (81.3)
How beneficial is the class
Somewhat beneficial	2 (12.5)
Very beneficial	14 (87.5)
Safety of the class
Somewhat safe	5 (31.3)
Very safe	11 (68.8)
Falls, injuries, or issues as a result of participating in this class
No	15 (93.8)
Yes	1 (6.3)
Change in mobility since attending the class
Much better	1 (6.3)
Somewhat better	6 (37.5)
A little better	3 (18.8)
About the same	5 (31.3)
A little worse	1 (6.3)
Somewhat worse	0 (0)
Much worse	0 (0)
Change in balance since attending the class
Much better	1 (6.3)
Somewhat better	7 (43.8)
A Little better	4 (25.0)
About the same	3 (18.8)
A little worse	1 (6.3)
Somewhat worse	0 (0)
Much worse	0 (0)
Change in mental health since attending the class
Much better	0 (0)
Somewhat better	2 (12.5)
A little better	4 (25.0)
About the same	9 (56.3)
A little worse	1 (6.3)
Somewhat worse	0 (0)
Much worse	0 (0)
Change in overall health since attending the class
Much better	0 (0)
Somewhat better	8 (50.0)
A little better	2 (12.5)
About the same	5 (31.3)
A little worse	1 (6.3)
Somewhat worse	0 (0)
Much worse	0 (0)

^aPercentages do not sum to 100% due to rounding.

Parkinson disease-specific survey

Participants completed the PDQ-39 between May and July 2020. Participants were asked to compare their changes in PD-related symptoms since starting the PDEx in-person (Table S2). For mobility-specific questions (1–10), 24% indicated improved mobility, whereas 74% indicated no change in mobility and 2% reported a decrease in mobility. For activities of daily living (ADL)-specific questions (11–16), 16% indicated improved ADL ability, 79% indicated no change in mobility, and 3% indicated decreased ADL ability. For emotional well-being questions (17–22), 18% indicated a positive change, 81% indicating no change, and 1% indicated a negative change. For stigma-related questions (23–26), 11% indicated an improvement, 88% indicated no change, and 2% indicated a worsening of stigma. For questions related to social support (27–29), 15% indicated improved support, 81% indicated no change, and no responses indicate social support had decreased. For cognition-specific questions (30–33), 11% indicated improved cognition, 70% indicated no change, and 19% indicated worsening of cognition. For questions related to communication (34–36), 8% indicated an improvement, 83% indicated no change, and 8% indicated a decrease. Finally, for questions related to bodily discomfort (37–39), 17% indicated an increase in discomfort, 71% indicated no change, whereas 9% indicated a decrease in discomfort. Over 30% of participant responses on the PFS-16 indicated an improvement in fatigue experience and effect of fatigue on daily functioning and activities since participating in PDEx (Table S3). Sixty-six percent of participant responses on the PFS-16 indicated no change, with only 2% of participants indicated a worsening of fatigue.

Focus group themes and subthemes

Three main themes and four subthemes were identified surrounding perceptions and experiences of in-person and virtual PDEx in PwPD.

Theme 1—Benefits of participating in a PD-specific exercise class

A majority of participants benefited from the social support by engaging in PDEx. All participants mentioned that a major facilitator for them continuing to participate in PDEx, regardless of delivery method, was the tailored nature of the program for PwPD, stating that participating in a PDEx was an “advantage” in maintaining their independence and function. Most participants also reported a sense of inclusivity and social support because of exercising with other PwPD.

All participants felt that both virtual and in-person classes were beneficial and increasingly “positive” to their quality of life. One participant stated that the PDEx was effective at keeping them active and mobile: “I felt like just trying to stay in shape was my best asset towards fighting this disease….” Three participants stated that the exercise program has addressed impairments beyond those specific to PD. One participant stated their use of medication had decreased: “I know it’s helped me, because I had some minor surgery…I was taking my Naproxen every day and I got off of it. So, I stayed off of it and I’m debating if I need it anymore. And the only reason I can think is because of the exercise.” Most participants felt that the exercise program increased their confidence with performing activities. One participant stated, “…it makes me feel like that I have reason not to feel uncomfortable with doing these things…. And now I definitely feel like there’s no reason why I can’t continue to do it. It’s given me a lot of confidence out of the program.”

Subtheme—A part of life

This subtheme illustrates the effect that PDEx has on the quality of life of PwPD. Most participants were grateful to participate in a tailored exercise program whether it was in-person or virtual, labeling the program as “complete” in addressing “all of the major body parts.” One participant indicated PDEx is incorporated into their daily routine and “has become a part of my life.” Other comments supporting this theme included “I can’t imagine stopping” and “If they decided not to do it, I would be very, very disappointed.”

Subtheme—I can relate to them

There was a consensus that a group setting provided social and emotional support by enabling PwPD to interact with each other: “I can relate to them. They can relate to me. And we can be supportive.” Participants felt they were “learning more” about PD from other class attendees, allowing them to become increasingly involved with their diagnosis. Most participants stated that attending class with people with a similar diagnosis was a motivator: “I think that helps me get out and do it…. you realize you’re with your peers.” A group setting enabled participants to create relationships beyond the exercise class space: “Even if it’s not even in the exercise group. Maybe we’re on the street or we’re at a store, we get to pause and catch up.”

Theme 2—Preference for virtual-PDEx

Overall, focus groups preferred virtual classes over in-person due to the convenience and safety. The inability to have their exercise form corrected hands-on by the course instructor was identified as the only challenge to the virtual classes. A majority of participants cited that virtual classes were “much more convenient” because they did not have to navigate barriers such as transportation and parking.

Subtheme—Accessibility, convenience, and safety of virtual classes

An unexpected subtheme that emerged from the focus groups was the ease of accessibility experienced with virtual classes. Due to previous exposure, most participants were largely “used to” navigating online sources. Two participants stated that they had received a tutorial from their spouse or family member. The convenience of virtual classes served as a major facilitator to adhere to PDEx: “I just think the convenience of the virtual classes is the thing that keeps me doing it” and “If we’re traveling then it’s hard to go to class…so, we can still do them.”

The virtual platform also allowed participants to minimize their risk of being exposed to SARS-CoV-2, considering their PD diagnosis: “…safety from the virus, it hangs on a lot of those things on me. I’ve got all on the list of things you shouldn’t have. I’ve got most of them.” Most participants were grateful to perform exercises despite COVID-19 temporarily shutting down most exercise facilities: “I was trying to do these exercises on my own before the virtual class was offered and when the gym was shut down. And I tried; I tried really hard, but I started to do them less and less often. It’s just easier to stay motivated.”

Subtheme—Challenges to participating in in-person classes

Transportation and parking were identified as challenges to attending in-person classes. Many participants identified traffic specifically: “just getting there sometimes can be a challenge, especially if the weather’s bad” and “you can either get really caught in traffic, going to, or from.” Another discussed the stress caused by traffic, describing a sense of relaxation with virtual classes: “…much more relaxed when you start exercising, when you don’t have to drive through the traffic.” Parking difficulties at the class site was another reported barrier to in-person classes.

Despite preferring virtual classes over in-person classes, most participants stated that they would still participate in PDEx in-person if virtual classes were discontinued. Participants noted that the effectiveness of the exercise program outweighed their preference: “If we never did Zoom and didn’t realize the benefits of it, I still don’t think I would have stopped it. I can’t think of a time, a reason why I would’ve stopped the in-person class.”

Theme 3—Lack of referral for PDEx

Most participants were referred to PDEx by a fitness instructor, family member, or friend rather than a physician, stating that disease-specific exercise programming was not generally offered by their health care provider: “I don’t remember any resource material.” One participant felt that the lack of exercise education was their fault for not asking: “I had a few questions, but I didn’t know enough to even ask good questions and I just never have; [the doctor] just doesn’t have the time. So that’s one of the reasons.” Those who did receive exercise education discussed the lack of tailored programming and resources provided: “…because I knew that exercise was supposed to be beneficial. I was just taking whatever I could find and worked out for me. And I didn’t know whether it was appropriate or not” and “[The doctor] said he did medication only.”

DISCUSSION

This mixed-methods study is the first, to our knowledge, to provide insight into perceptions of PwPD of a PDEx that started in-person and transitioned to virtual delivery because of a global pandemic. Collectively, our quantitative and qualitative results suggest that transitioning to a virtual PDEx has a positive effect for PwPD to maintain or improve physical function.

Consistent with previous studies, our findings suggest that group exercise programming for PwPD improves PD-related motor symptoms.^6,7,9 Survey and focus group participants indicated that they perceived improved mobility and balance since attending PDEx, despite the transition to virtual. Focus group participants reported that the program had become a daily routine and a “positive asset” toward controlling their PD-related symptoms. Our findings are in accordance with a systematic review of 19 studies indicating that PwPD view physical activity as an enjoyable and positive experience that aids in controlling symptoms and enhancing quality of life.²¹

Despite reported improvements in physical function, 66% and 81% of participant responses from the PD-specific surveys show that fatigue and mental health, respectively, were unchanged since attending either PDEx class. However, in the Survey, 38% reported an improvement in mental health. The differences in results were potentially due to how the survey questions were worded, as the PD-specific surveys asked about specific questions/scenarios concerning fatigue and mental health versus the generic prompt in the Survey of just the term mental health (Tables 1–3), which may have changed participants’ interpretation when answering the questions. Given that PD is also a progressive disease, a lack of change in mental health or fatigue in the PD-specific surveys may still indicate that participants benefited from participation in physical activity virtually.²² Conversely, the lack of change in fatigue and mental health may be due to restrictions imposed to mitigate the spread of COVID-19.²³ A cross-sectional survey by Pearman et al. on 515 adults 20 to 79 yearsold found that lower COVID-related anxiety in older adults was associated with safety measures and restrictions to mitigate the spread of COVID-19.²⁴ Although there is no baseline data from before the pandemic, on average, survey respondents indicated cognition, communication, and bodily discomfort worsened since participating in the PDEx. Worsening of communication and cognition could be attributed to the COVID-19 pandemic decreasing social activities. Douglas and colleagues found that participation in social gatherings is associated with the maintenance of cognition in older adults.²⁵ Our findings of increased bodily discomfort could also be due to PwPD decreasing activities overall during the pandemic. Focus-group participants stated that virtual PDEx became their only form of activity since the pandemic.

In our study, focus-group participants expressed feeling socially isolated during the pandemic and reported that PDEx enabled them to engage with others. Focus-group participants emphasized the importance of virtual PDEx to maintain social connections, specifying that a group of PwPD provided social and emotional support and improved confidence to exercise, which is supported by recent studies.^26,27 Quinn et al. described the sustainability of modifications to the Engage physical activity program for PwPD to adapt to stay-at-home guidelines during the pandemic by delivery via Zoom.¹⁰ They found that the recruitment rate was 52%, speculating this may be due to participants having limited access to in-person programs during the pandemic, whereby the modified Engage program filled a need. Collectively, these studies indicate that virtual programs for PwPD are feasible and can counteract the negative consequences of stay-at-home ordinances through maintenance of social connections and physical activity via digital solutions such as programs like PDEx.²⁸

Lack of provider referral was an unexpected barrier to PDEx. Most participants discovered PDEx through family and friends rather than their physician. According to the Michael J. Fox Foundation for Parkinson’s Research survey, only 45% of PwPD felt informed of where to find services and information, and how to connect with local community programs.²⁹ Future implementation studies should identify barriers to physician referrals.

Most participants who attended both in-person and virtual PDEx had minimal difficulty using technology to attend virtually. These findings are consistent with a series of surveys conducted by SilverSneakers; of over 5000 older adults, 67% reported an increase in comfort using digital platforms during the COVID-19 pandemic, and 83% reported using virtual platforms for video calls or exercise.³⁰ In our study, focus-group participants indicated that time, convenience, comfort at home, fear of contracting COVID-19, and transportation barriers supported their preference for virtual classes. Despite the focus groups’ overwhelming preference of virtual classes compared to in-person classes, only 25% of survey participants preferred virtual classes, with a majority of participants preferring both in-person and virtual classes (56%). This discrepancy can be explained by focus-group participants potentially being more comfortable participating in an online focus group and/or being more tech savvy and comfortable with virtual platforms.

The results of our study are the first, to our knowledge, to describe perceptions of PwPD regarding PDEx that started in-person and transitioned to virtual delivery as a result of a global pandemic. With COVID-19, the virtual transition of exercise programs has created opportunities to improve dissemination and access to older adults, especially those with progressive neurological disorders. Helmich and Bloem suggest that creating dosed home-based training programs to increase physical activity might mitigate the negative effect of the COVID-19 pandemic.³¹ Digital solutions to exercise programming are necessary to maintain or improve function in PwPD who are home-bound for any number of reasons.

Study limitations and further research

Our study had several limitations. The use of a cross-sectional, one-time survey and focus groups may have been selective for participants who felt comfortable with technology or the program. The inability to conduct in-person, functional outcome measures limited the study to using only self-reported measures. The self-report measures (PDQ and PFS) were also revised to change scales due to the cross-sectional nature of the study, which may limit interpretation of those results. The frequency of class attendance (in-person or virtual) was not recorded and the term “regularly attended PDEx” was not defined in the survey and thus was left up to the interpretation of the respondent. The data do not represent the period of time during the transition to virtual PDEx classes, in which the lack of in-person interaction experienced before virtual PDEx classes began could have posed negative effects such as social isolation. Because this study was completed during the virtual PDEx program, there is a possibility of recency bias and recall bias from the in-person PDEx to the virtual PDEx. The sample size of our study is also another limitation as it potentially does not truly represent PwPD. Only 9 participants were in focus groups compared to the 16 participants who completed the surveys. Hence, there may be a potential bias within the study where the focus-group participants may have preferred virtual more than those participants who decided not to participate in the focus groups. Older adults can experience difficulties accessing the technology required for virtual exercise programs^32,33; thus, those who had such difficulty may not have participated in both class formats due to their inability to navigate the virtual platform rather than preferring not to participate. Further studies are warranted on the use of technology for virtual programs with older adults who are novices with technology.

CONCLUSION

This study suggests that PwPD feel that virtual PDEx is a viable exercise option and helps address some PD- and non-PD-related symptoms.⁷ PwPD value PDEx, yet few health care providers refer to these programs, which should be addressed in future programming. Virtual exercise programs can reach individuals who are home bound or have limited access, particularly due to the constraints of the COVID-19 pandemic, or for PwPD who do not have access to in-person exercise programming. PwPD perceived that the PDEx provided social and emotional support and improved confidence to exercise. Expanded access to virtual programs could be a vital component that helps PwPD to maintain physical activity, mobility, and social support, which are crucial to function, quality of life, and independence.