Self‐Reported Barriers to Exercise and Factors Impacting Participation in Exercise in Patients with Parkinson's Disease

Exercise has proven benefits for symptoms of Parkinson's disease (PD)1, 2, 3 but patients with PD (PWPD) report engaging in low levels of exercise. ⁴ , ⁵ , ⁶ Limited data suggest different reported barriers to exercise in PWPD and beliefs about exercise. ⁴ , ⁵ , ⁶ No study has examined whether the reported barriers and reports of participation differ depending on exercise type (ie, self‐directed exercise, physical therapy [PT], or community‐based exercise programs [CBP]). By surveying PWPD to obtain data on beliefs about the benefits of exercise, perceptions regarding barriers to different types of exercise, ratings of mood and disease severity, and participation in various exercise, we hoped to identify ways to potentially increase participation in exercise.

During visits to Allegheny Health Network Movement Disorder clinics, 339 PWPD completed voluntary questionnaires (see File S1). Based loosely on American Health Academy guidelines, patients were grouped as greater exercisers (GE), defined as reporting exercising at least 150 minutes per week, versus lesser exercisers (LE). Data were tabulated as means and percentages. The t test, chi‐square test, and Mann‐Whitney U test were used to test for between‐group differences. Stepwise logistic regression was used to determine the variables most predictive of exercise classification.

Consistent with published data, ⁵ , ⁶ a majority of participants (86%) reported being encouraged to exercise and believing exercise was beneficial (90%). Low energy (36%), physical symptoms (33%), and fear of falling (30%) were the most frequently reported barriers for all types of exercise. Table 1 breaks down the most frequently reported barriers by exercise type. Referrals, reported participation rates, and barriers varied greatly between exercise types (Tables S3 and S4). Examining participation by referral rates showed that 90% of the 56% of PWPD reporting referrals also reported participating in PT versus 65% of the 43% referred to CBP. A majority of the participants (62%) reporting participation in PT reported continuing to do the learned exercises following PT. Estimated time exercising ranged from 0 to 840 min/week (mean = 136, standard deviation = 143). Only 37% met our minimal criteria for GE. Current age, age at onset, age at diagnosis, and disease duration were not significantly different (P > 0.70) between GE and LE (Table S1). Self‐reported mood, PD disease severity, and health ratings were significantly different between GE and LE (P < 0.012; Table S2). Correlations between these ratings were significant but weak to moderate (r = 0.29‐0.41; P < 0.01). Stepwise regression analysis results are presented in Table S5; the strongest predictors of being an LE were reporting concerns about increased physical symptoms when exercising, lower overall health rating, and low energy (P ≤ 0.01).

TABLE 1.

Percentages of participant‐reported barriers to exercise based on exercise type

Characteristic	All Participants, %	GE, %	LE, %
Low energy
Self‐exercise	28	14	36
Physical therapy	12	7	16
Community‐based programs	27	16	34
Physical symptoms
Self‐exercise	23	13	31
Physical therapy	14	4	20
Community‐based programs	26	14	36
Fear of falls
Self‐exercise	22	18	27
Physical therapy	12	8	15
Community‐based programs	22	17	27
Freezing of gait
Self‐exercise	9	8	11
Physical therapy	6	5	7
Community‐based programs	11	8	14

Abbreviations: GE, greater exercisers; LE, lesser exercisers.

Significant limitations of this study include relying on self‐reports and not using validated instruments for measuring mood, disease severity, and exercise. We are unable to determine if GE were meeting American Health Academy guidelines for recommended intensity levels for exercise. However, asking patients for brief global assessments of health, mood, and exercise participation is similar to data collection methods in clinical situations, and these types of data impact clinical care decisions. These self‐report data provide potentially useful information for attempting to improve exercise participation. Fear of falling was the only barrier reported as a top barrier in prior studies. ⁴ Using quick screening and designing algorithms to assess for and address concerns about low energy, physical symptoms, and fear of falling may improve exercise participation. Given the reported high participation rates in PT after referral and the fact that a majority of participants reported continuing to do the learned exercises, increasing the number of referrals to PT may increase the rates of exercise. Since less than half of the respondents reported being referred for CBP and more than half reported participating after referral, increasing the number of CBP referrals may also be indicated. LE in particular may benefit from attempts to address concerns about physical symptoms that make exercise difficult.

Author Roles

(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique.

P.P.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B

T.F.S.: 1A, 1B, 3B

S.M.B.: 1A, 1B, 1C

T.L.: 1A, 1B, 1C

C.J.S.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B

Disclosures

Ethical Compliance Statement: We submitted our project to our institutional review board (IRB) of Allegheny General Hospital (Allegheny Senior Research Institute ‐ West Penn Allegheny Health System IRB) as a quality assurance/quality improvement project initiative. After IRB review, we were informed that no approval from IRB was deemed necessary. The authors confirm that the approval of an institutional review board was not required for this work. The authors confirm that formal informed consent was not obtained. However, patients were informed that participation in the survey was voluntary and that patient care would not be impacted by participation. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Funding Sources and Conflicts of Interest: There was no specific funding received for this work. The authors declare that there are no conflicts of interest relevant to this work.

Financial Disclosures for the Previous 12 Months: Dr. T.F. Scott has received payments for research activities, advisory boards, promotional speaking, and consulting for Genentech, Biogen, Novartis, and Genzyme. Dr. C.J. Schramke and spouse own more than $10,000 worth of Pfizer stocks. Dr. S.M. Baser is on an advisory board and speakers bureau of US World MedS, an advisory board and speakers bureau of Adamas, and a speakers bureau of TEVA. All other authors declare that there are no additional disclosures to report.

Supporting information

Table S1. shows the demographic data (including current age, age at first PD symptom onset, age at PD diagnosis, and disease duration) of all participants as well as those in the subgroups of greater and lesser exercisers.

Table S2. Shows the percentages of participant reported responses for PD disease severity, mood, and overall health.

Table S3. Shows the percentages of participant reported responses for referral and participation rates.

Table S4. Shows the frequencies of reported barriers among all participants based on the exercise type (n = 339).

Table S5. Shows the results of the forward stepwise logistic regression analysis for best predictors for assignment to the greater exercise group.

File S1. Includes a sample of the survey that was submitted to the participants.