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artigo 02 Motivators and Barriers to Exercise

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Journal of Parkinson’s Disease 7 (2017) 703–711
DOI 10.3233/JPD-171173
IOS Press
Research Report
Motivators and Barriers to Exercise
in Parkinson’s Disease
Mitra Afsharia,b,∗ , Amy Yangc and Danny Begaa
a Department
of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
of Neurology, University of California, San Francisco, CA, USA
c Biostatics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
b Department
Accepted 5 October 2017
Abstract.
Background: Despite evidence for the benefits of exercise in Parkinson’s disease (PD), many patients remain sedentary for
undefined reasons.
Objective: To compare exercise habits, perceptions about exercise, and barriers to exercise in ‘low’ (<3 h/week) and ‘high’
(≥3 h/week) exercisers with PD.
Methods: A 48-item survey was administered to PD patients at an outpatient academic center. Chi-squared tests were used
to compare the percentage differences between low- and high-exercisers with two-sided tests and a significant level of 0.05.
Results: 243 surveys were collected over three months; 28 were excluded due to incomplete data, leaving 215 to be analyzed.
49.3% reported ‘low’-exercise and 50.7% reported ‘high’-exercise. High-exercisers participated in higher intensity exercise
regimens (83.4% versus 32.1%, p ≤ 0.001). High-exercisers were more likely to start exercising after being diagnosed (54.2%
versus 27.8%, p < 0.001), whereas low-exercisers were more likely to reduce their amount of exercise (40.2% versus 15.9%,
p < 0.001). Low-exercisers required more motivating factors. Both groups benefited from having a significant other or a
personal trainer motivate them, and both were more likely to exercise if their neurologist encouraged them. Low-exercisers
reported twice as many barriers as high-exercisers (p = 0.001). Barriers that were significantly more common in low-exercisers
were: lacking someone to motivate them (33.3% versus 10.5%, p < 0.001), fatigue (20.8% versus 15.2%, p = 0.005), and
depression (16.7% versus 7.6%, p = 0.045).
Conclusions: There are significant differences between people with PD who exercise regularly and those who do not in
terms of motivators and barriers. These findings should be considered when tailoring recommendations for PD patients to
encourage exercise, and in designing future interventions.
Keywords: Adult, exercise, falls, Parkinson’s disease, physical activity, quality of life
INTRODUCTION
Encouraging exercise has become an integral part
of the management of Parkinson’s disease (PD) as
data on the beneficial effects of different exercise
∗ Correspondence
to: Mitra Afshari, MD, MPH, Clinical Movement Disorders Fellow, UCSF Movement Disorder and Neuromodulation Center, 1635 Divisadero St., Suite 520-530,
San Francisco, CA 94115, USA. E-mail: [email protected]
modalities continues to expand. Aerobic [1, 2],
strength-training [3, 4], yoga [5, 6], Tai Chi [7],
forced exercise [8], and even virtual reality [9] for
gait training have been shown to augment motor function, prolong functional independence, and improve
quality of life. The National Parkinson Foundation
(NPF) has emphasized the importance of exercise
as part of the standard-of-care for patients based on
data obtained from PD Centers of Excellence (COE)
ISSN 1877-7171/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
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M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
around the United States. Despite the growing evidence and awareness of the importance of exercise,
many PD patients do not exercise regularly. Analysis of the NPF QII Registry was able to identify
that 56% of PD patients did not exercise regularly,
and that these patients had worse quality of life,
worse physical function, more progression of disease,
and more caregiver burden even after controlling
for disease duration, disease severity, cognition, and
demographics, both in a cross-sectional and one-year
longitudinal analysis [10].
In a clinical setting, discussions of exercise are
limited by our incomplete understanding of the variables that most influence activity versus inactivity
in this patient population. If we can better understand the differences between regular exercisers and
non-exercisers, we may be able to transform the latter population into the former. One cross-sectional
study did look at the barriers to engaging in exercise
in PD patients and compared an exercise group to
a non-exercise group, distinguished based on both
patient report and an activity monitor [11]. They
found that fear of falling, lack of time, and lowoutcome expectation (i.e., participants did not expect
to derive benefit from exercise) were significant barriers in the non-exercise group. We were interested in
verifying this finding, but also understanding the difference between the two populations with regards to
beliefs about exercise and the ideal exercise settings
that would lead to increased participation.
The objective of this study was 1) to compare the
beliefs and knowledge about exercise and its benefits in PD among exercisers and non-exercisers, 2)
to identify the exercise conditions and motivators for
exercise that are most likely to lead to exercise compliance, and 3) to assess barriers to exercise and how
these differ between groups.
MATERIALS AND METHODS
Design
This was a cross-sectional study in which a 48-item
survey was administered to patients with PD between
October 2015 and January 2016. There were 215
study participants recruited from the Northwestern University PD & Movement Disorders Center
(NUPDMDC) as they presented for their regularly
scheduled clinic visits. NUPDMDC is a NPF COE
staffed by 4 fellowship-trained Movement Disorders
specialists, in which over 2,000 patients with PD are
seen annually. Every patient seen for PD between
October 2015 and January 2016 was presented
with the optional survey which included multiplechoice and Likert-scale-based questions regarding
their PD symptoms, exercise habits, perspectives
on the benefit of exercise, preferences regarding
exercise regimens, and perceived barriers to their
own participation in exercise. Subjects were asked
to recall an estimate of their average amount of
exercise per week using a Likert-scale of ‘none,’
‘<3 hours,’ and ‘≥3 hours.’ Surveys were completed while waiting for their appointments and then
returned to their Movement Disorders specialist who
would 1) determine whether the patient met inclusion criteria or any exclusion criteria and separate
the surveys accordingly, and 2) answer 5 nonidentifying questions regarding the patient’s disease,
antidepressant use, and deep-brain stimulation (DBS)
status. No patient identifiers were included in the
survey.
All participants met the following inclusion criteria: age of 18 years or over and confirmed to
have a diagnosis of idiopathic PD by a Northwestern Movement Disorders specialist. Participants were
excluded if they had a diagnosis other than idiopathic PD, such as atypical parkinsonism or the
diagnosis was in question, if they had a concurrent neurologic condition that rendered them with
severe disability (i.e., major stroke or head injury),
and/or if they were unable to complete the survey
adequately due to severe cognitive impairment or language barrier. Excluded surveys were discarded in a
HIPAA-compliant manner by their physician.
This study was approved by the Institutional IRB
and a waiver of consent was obtained.
Measures
Based on the survey responses, participants were
categorized into two groups: low-exercisers (those
who reported less than 3 hours per week) and highexercisers (those who reported more than or equal to
3 hours per week). This distinction used a slightly
higher cutoff than the American Heart Association’s
recommended guideline of 150 minutes of moderate
exercise per week. All survey responses were compared between these groups.
Data was collected on demographics and basic
disease characteristics. This included employment
status, living environment, exercise practices, years
from PD diagnosis, primary perceived motor symptom, presence of depression, cognitive impairment,
or orthostasis, antidepressant use, and DBS status.
M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
Beliefs and knowledge
First, with regards to perceptions regarding exercise and PD, participants were asked how often their
Movement Disorders specialist would talk to them
about exercise, how their exercise habits changed
since their PD diagnosis (i.e., less, more, or same), if
they believed there is scientific evidence showing that
exercise can slow the progression of PD symptoms,
and their view on the potential impact of exercise
on motor symptoms of speed of movements, balance
and fall risk, and tremor, and non-motor symptoms
of mood, memory, fatigue, and sleep.
705
pare the percentage differences between the low- and
high-exercise groups. We used Fisher’s exact tests
when the cell count was less than the expected in
any of the cross tabulations. The number of barriers
had a skewed distribution, thus the non-parametric
Wilcoxon rank sum test was used to compare the
number of barriers between the groups. Two-sided
tests and a significant level of 0.05 were used for all
tests. Analyses were performed in R: A language and
environment for statistical computing (R Foundation
for Statistical Computing, Vienna, Austria, version
3.3.0).
RESULTS
Optimal exercise conditions and motivators to
exercise
Second, participants were asked to indicate their
likelihood of participating in exercise under certain
conditions on a Likert-scale of ‘less likely,’ ‘does
not matter,’ and ‘more likely,’ in order to determine
which environmental variables would lead to the best
exercise compliance. The 13 options included exercising alone, in a group, with an “exercise buddy,”
with a significant other, with a personal trainer, with
a group instructor, for <30 minutes, for 30–60 minutes, as a means of transportation, with equipment,
with the same routine each time, with a different routine each time, and if their Neurologist told them it
was necessary.
Barriers to exercise
And finally, participants were asked what makes
it difficult for them to exercise on a 5-item Likertscale of ‘strongly-agree’ to ‘strongly-disagree,’ in
order to identify variables that lead to poor exercise compliance. The 15 options included fear of
falling, history of falls, having no one to exercise with
or motivate them, hindering PD symptoms, lack of
time, fatigue, excessive daytime sleepiness, depression, lack of exercise experience, disliking exercise,
low-outcome expectation, lack of necessity, and other
hindering medical conditions.
Analysis
Simple descriptive statistics including mean (SD),
median (interquartile range) and count (percentage)
were reported for the whole sample, as well as for
the low- and high-exercise groups. For categorical
questions, we performed Chi-squared tests to com-
Surveys were completed by 215 PD patients.
Surveys from 28 patients were excluded due to
incomplete data. There were no patients who refused
to complete the survey. The mean age and gender breakdown of the PD patients seen in the
NUPDMDC over the period in which data was
obtained was 68 years, 63% male, and 37% female,
respectively. Of the 215 participants, 49.3% (N = 106)
reported low-exercise (i.e., <3 hours/week) and
50.7% (N = 109) reported high-exercise (i.e., ≥3
hours/week). These groups differed significantly only
with respect to living arrangements and employment
status, with low-exercisers being more likely to live
in a retirement community or nursing home and
less likely to be employed. There were no significant between-group differences in disease duration
or key motor and non-motor symptoms questioned
(Table 1). Of note, only 7.9% of our study population
had DBS.
Participants engaged in the following exercise regimens: walking (73.5%), strength-training
(34.9%), physical therapy (29.8%), cycling (23.3%),
yoga (12.6%), swimming (7.9%), running (7%),
dance (4.7%), Tai Chi (4.7%), and other (19.1%)
(Table 2). Of the various exercise regimens participants engaged in, the most common were those that
would be considered low-intensity. High-exercisers
had statistically significantly higher participation in
both strength-training and cycling, both considered
to be higher-intensity regimens (50.5% and 33% versus 18.9% and 13.2%, total 83.4% versus 32.1%,
p < 0.001, p = 0.001).
Beliefs and knowledge
Participants were generally well-educated about
the importance of exercise, but high-exercisers were
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M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
Table 1
Participant demographics and disease characteristics
Low-exercisers
n = 106 (49.3%)
20 (18.9%)
84 (79.2%)
92 (86.8%)
14 (13.2%)
44 (51.2%)
21 (23.1%)
34 (37.4%)
32 (35.2%)
0 (0.0%)
3 (3.3%)
32 (38.6%)
28 (33.7%)
22 (26.5%)
39 (41.1%)
8 (8.0%)
Employed
Live with someone
Live in private home
Live in retirement community/nursing home
PD diagnosis >5 years
Main motor symptom: tremor
Main motor symptom: balance/gait
Main motor symptom: both
Main motor symptom: neither
Main motor symptom: unclear
Experience depression
Experience cognitive impairment
Experience lightheadedness
On an antidepressant
Have DBS
High-exercisers
n = 109 (50.7%)
40 (36.7%)
87 (79.8%)
106 (98.1%)
2 (1.9%)
42 (40.4%)
36 (34%)
37 (34.9%)
29 (27.4%)
1 (0.9%)
3 (2.8%)
35 (38.0%)
24 (26.1%)
26 (28.3%)
40 (37.7%)
9 (8.3%)
Total†
n = 215
60 (27.9%)
171 (79.5%)
198 (92.1%)
16 (7.4%)
86 (40.0%)
57 (26.5%)
71 (33.0%)
61 (28.4%)
1 (0.004%)
6 (0.03%)
67 (31.2%)
52 (24.2%)
48 (22.3%)
79 (36.7%)
17 (7.9%)
p-value
0.006
>0.999
0.002
0.002
0.180
0.128
0.834
0.560
>0.999
>0.999
>0.999
0.347
0.928
0.737
>0.999
† Mean
age and gender breakdown of the PD patients seen in the NUPDMDC over the period in which data was obtained
was 68 years, 63% male, and 37% female, respectively.
Table 2
Participant exercise regimens
Walking
Strength-training
Physical therapy
Cycling
Other
Yoga
Swimming
Running
Dance
Tai Chi
None
Low-exercisers
76 (71.7%)
20 (18.9%)
33 (31.1%)
14 (13.2%)
17 (16.0%)
11 (10.4%)
8 (7.5%)
8 (7.5%)
3 (2.8%)
6 (5.7%)
2 (1.9%)
High-exercisers
82 (75.2%)
55 (50.5%)
31 (28.4%)
36 (33.0%)
24 (22.0%)
16 (14.7%)
9 (8.3%)
7 (6.4%)
7 (6.4%)
4 (3.7%)
0 (0.0%)
significantly more likely to change their habits to
exercising more since their PD diagnosis (54.2% versus 27.8%, p < 0.001), whereas low-exercisers were
actually more likely to reduce their amount of exercise (40.2% versus 15.9%, p < 0.001) (Table 3a).
More than 50% of participants, both low- and highexercisers alike (56.7% and 64.7%), reported that
their Movement Disorders specialist spoke to them
about exercise at every clinic visit. However, amongst
the two groups, high-exercisers were significantly
more likely to believe that there is scientific evidence
that exercise could potentially slow the progression
of PD symptoms (78% versus 62.5%, p = 0.033).
With regards to motor symptoms, there was no
statistically significant difference between the two
groups on their perceptions on potential impact of
exercise. However, with regards to non-motor symptoms, high-exercisers were more likely to believe
that exercise improves mood (89.3% versus 71.6%,
p = 0.003) and sleep (70.6% versus 56.7%, p = 0.002)
than low-exercisers. There was a statistically significant higher incidence of non-motor symptoms
self-reported among low-exercisers, 36.4% versus
Total
158 (73.5%)
75 (34.9%)
64 (29.8%)
50 (23.3%)
41 (19.1%)
27 (12.6%)
17 (7.9%)
15 (7.0%)
10 (4.7%)
10 (4.7%)
2 (0.9%)
p-value
0.666
<0.001
0.778
0.001
0.346
0.456
>0.999
0.955
0.333
0.534
0.465
26.4% with memory difficulty (p = 0.050), 47.5%
versus 35.8% with excessive fatigue (p = 0.018),
and 33.7% versus 25.7% with excessive sleepiness
(p = 0.027) (Table 3b).
Optimal exercise conditions and motivators to
exercise
The motivating factors and non-factors that were
reported by ≥50% of low-exercisers and highexercisers are summarized in Fig. 1. Low-exercisers
reported 7 of 13 to be motivating factors including
having their Neurologist say exercise was necessary,
exercising with a personal trainer, significant other,
exercise buddy, in a group, or with a group instructor, and exercising shorter durations at a time (<30
minutes compared to 30–60 minutes long). On the
other hand, high-exercisers did not report as many
motivating factors as did the low-exercisers, only 3
of 13. Like the low-exercisers, high-exercisers were
motivated by exercising with a personal trainer or
significant other, and having their Neurologist tell
them exercise was necessary.
M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
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Table 3a
Perceptions of exercise
Change in exercise since PD diagnosis
Low-exercisers
High-exercisers
Believe scientific evidence for positive impact of exercise
Low-exercisers
High-exercisers
Impact of exercise on bradykinesia
Low-exercisers
High-exercisers
Impact of exercise on balance and fall risk
Low-exercisers
High-exercisers
Impact of exercise on tremor
Low-exercisers
High-exercisers
Impact of exercise on mood
Low-exercisers
High-exercisers
Impact of exercise on memory
Low-exercisers
High-exercisers
Impact of exercise on fatigue
Low-exercisers
High-exercisers
Impact of exercise on sleep
Low-exercisers
High-exercisers
More
27 (27.8%)
58 (54.2%)
Yes
65 (62.5%)
85 (78.0%)
Improves
59 (64.1%)
74 (73.3%)
Improves
53 (58.9%)
74 (73.3%)
Improves
30 (33.3%)
34 (34.7%)
Improves
68 (71.6%)
92 (89.3%)
Improves
41 (45.1%)
45 (43.7%)
Improves
47 (54.0%)
63 (60.6%)
Improves
51 (56.7%)
72 (70.6%)
Less
39 (40.2%)
17 (15.9%)
No
8 (7.7%)
3 (2.8%)
Worsens
7 (7.6%)
3 (3.0%)
Worsens
9 (10.0%)
5 (5.0%)
Worsens
6 (6.7%)
8 (8.2%)
Worsens
2 (2.1%)
1 (1.0%)
Worsens
1 (1.1%)
1 (1.0%)
Worsens
14 (16.1%)
12 (11.5%)
Worsens
8 (8.9%)
0 (0.0%)
Same
31 (32.0%)
32 (29.9%)
Unsure
31 (29.8%)
21 (19.3%)
No effect
28 (31.1%)
22 (21.8%)
No effect
28 (31.1%)
22 (21.8%)
No effect
53 (58.9%)
56 (57.1)
No effect
25 (26.3%)
10 (9.7%)
No effect
49 (53.8%)
57 (55.3%)
No effect
26 (29.9%)
29 (27.9%)
No effect
31 (34.4%)
30 (29.4%)
p-value
<0.001
0.033
0.229
0.097
0.871
0.003
0.942
0.565
0.002
Table 3b
Perceptions of non-motor symptoms
“I experience this symptom on most days.”:
Depression
Memory Difficulty
Excessive Fatigue
Excessive Sleepiness
Low-exercisers
High-exercisers
Total
p-value
24 (24.2%)
36 (36.4%)
48 (47.5%)
34 (34.0%)
16 (15.1%)
28 (26.4%)
38 (35.8%)
27 (25.7%)
40 (19.3%)
64 (30.9%)
86 (41.5%)
61 (29.4%)
0.101
0.050
0.018
0.027
Barriers to exercise
Finally, participants were asked about 15 potential
barriers to exercise (Table 4). The median number of
barriers to exercise reported by low-exercisers was
twice that of high-exercisers (2 versus 1, p = 0.001).
Barriers that were significantly more common in the
low-exercise group were: having no one to exercise with or motivate them (33.3% versus 10.5%,
p < 0.001), fatigue (20.8% versus 15.2%, p = 0.005),
and depression (16.7% versus 7.6%, p = 0.045). Fear
of falling, lack of time, and low-outcome expectation
were not identified as being significant barriers that
would differentiate the low- and high-exercisers in
this study. Thirteen patients, 8 low-exercisers and 6
high-exercisers, reported medical conditions preventing participants from exercising including arthritis,
osteoporosis, back, hip, and knee pain, herniated
discs, spinal stenosis, and radiculopathy.
DISCUSSION
This study shows that there are significant differences between people with PD who exercise regularly
compared to those who do not in terms of their beliefs
about exercise, their ideal exercise conditions and
motivators for exercise, and their specific barriers
to exercise. With the growing evidence that exercise improves PD outcomes and quality of life, it is
important for Neurologists to identify motivators and
barriers to exercise and provide appropriate recommendations to patients. Likewise, it is important for
communities to design exercise programs that meet
the needs of PD patients in a way that increases their
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M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
likelihood of compliance and success with regards to
exercise frequency, duration, and intensity. Our study
is the first to demonstrate the differences between the
beliefs and needs of low- and high-exercisers in PD.
The study offers important findings that can lend to
evidence-based guidelines for exercise in PD.
Beliefs and knowledge
Fig. 1. Motivators to exercise: Motivating factors and noninfluential factors that were reported by ≥50% of low-exercisers
and high-exercisers.
First, our findings support the concept of selfefficacy as it relates to exercise behavior in PD
patients, playing a dual role as a predictor and an
outcome of exercise. Since receiving their diagnosis of PD, our high-exercisers were more likely to
change their habits to exercising more, whereas our
low-exercisers changed their habits to exercising less.
High-exercisers were also more likely to participate
in higher-intensity exercise regimens, often participating in both aerobic exercise and strength-training.
Studies have shown that progressive resistancetraining, that is inherently more challenging and
generates large forces that further increase neuronal
activation in the basal ganglia, can increase not
only the strength but also the speed of movements,
thereby improving PD motor control [3, 12, 13]. This
could be thought of as a “higher dose” of exercise.
The heightened benefit from higher-intensity exercise
may feedback into higher levels of self-efficacy. In
fact, most recently, researchers have examined reward
signaling in the ventral striatum of PD patients who
are habitual exercisers versus sedentary and participated in aerobic cycling versus controls/stretching
only using an fMRI-based monetary incentive task.
Table 4
Barriers to exercise
Median number [interquartile range] of barriers reported:
Individual barriers:
I am scared I would fall.
I have fallen in the past.
There is no one to exercise with or motivate me.
I am afraid of “slowing” down others in a class.
My Parkinson’s symptoms really get in the way.
I do not have easy access to an exercise facility.
I do not have enough time during my day.
I am so tired during the day.
I am so sleepy during the day.
I feel depressed.
I never really exercised before.
I do not enjoy exercising.
My neurologic disease will progress no matter what I do, so I do not see a need.
My neurologic medications already help me enough physically, so I do not see a need.
My other medical conditions prevent me from it.
Low-exercisers
High-exercisers
p-value
2 [1, 4]
1 [0, 3]
0.001
29 (30.2%)
27 (28.1%)
32 (33.3%)
10 (10.4%)
27 (28.1%)
21 (21.9%)
10 (10.4%)
34 (35.4%)
20 (20.8%)
16 (16.7%)
8 (8.3%)
13 (13.5%)
6 (6.2%)
3 (3.1%)
11 (11.5%)
20 (19.0%)
25 (23.8%)
11 (10.5%)
13 (12.4%)
19 (18.1%)
14 (13.3%)
9 (8.6%)
18 (17.1%)
16 (15.2%)
7 (6.7%)
8 (7.6%)
15 (14.3%)
2 (1.9%)
2 (1.9%)
7 (6.7%)
0.094
0.592
<0.001
0.830
0.128
0.159
0.837
0.005
0.396
0.045
>0.999
>0.999
0.225
0.671
0.347
M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
They have shown that in the habitual exercisers and
after three months of aerobic exercise, there was
higher fMRI signal in the ventral striatum, suggesting that aerobic exercise alters the function of reward
circuitry, potentially through enhanced transmission
in the mesolimbic dopamine system [14].
Second, our findings revealed that non-motor PD
symptoms could be just as important as motor symptoms in hindering the PD patient in adopting regular
exercise. Low-exercisers were less likely to believe
that exercise improves mood and sleep, despite considerable evidence in the literature supporting this
and the considerable impact non-motor symptoms
have on quality of life [15, 16]. High-exercisers, on
the other hand, did believe in the benefits of exercise
on these symptoms. Low-exercisers reported depression and fatigue as barriers to exercise, and reported
a higher incidence of these symptoms compared to
the high-exercisers, however they were less likely to
believe that exercise could help these symptoms. The
number of subjects actually reporting these symptoms as barriers to exercise was a small subset of the
entire cohort, and rates of a diagnosis of depression
were actually very similar amongst the two groups,
as were the rates of antidepressant use: 38.6% and
41.1% among low-exercisers, and 38% and 37.7%
among high-exercisers (Table 1). Perhaps a subset of
low-exercisers experience either more severe depression or poorly-controlled depression, although these
symptoms may also be under-reported and underrecognized. This argues that clinicians should pay
special attention to treating mood, fatigue, and sleep
as part of their efforts in motivating exercise, not
to mention educate patients about the potential nonmotor benefits of exercise.
Optimal exercise conditions and motivators to
exercise
709
ing physical therapists and physiatrists. Educational
events discussing the importance of exercise may also
be beneficial. There is strong evidence in the primary
care community that advice from health professionals
significantly influences adoption of healthy lifestyle
behaviors including regular physical activity [17].
This underscores the importance of clinicians and
physical therapists talking to their patients about
their exercise habits, encouraging significant others’
or family members’ involvement, and routinely recommending group PD exercise classes as part of
standard-of-care.
Similar findings have been found with other
chronic diseases that directly affect movement like
PD, such as arthritis, the leading cause of disability in the United States. In one qualitative study
of 68 community-dwelling adults with arthritis, the
symptoms related to arthritis such as pain, stiffness,
fatigue, and mobility issues were perceived as barriers to exercise, but improvement in these outcomes
were also seen as potential motivators for exercise.
In this focus-group-based study, exercisers identified
that they were more likely to make adaptations to
their regimens to account for these specific barriers (i.e., modify the type or intensity, take a respite
during flares, and work through the pain to attain
benefits), whereas non-exercisers were more likely
to quit. The findings of this study and ours underlines
the importance of aligning our health communication
messages and exercise recruitment strategies with
expectations [18].
The data depicted in Fig. 1 should be considered
in designing future exercise programs for people with
PD. At least with regard to this cohort, a group class,
led by an instructor, that lasts less than 30 minutes, and allows spouses or significant others to be
included, may lead to improved compliance.
Barriers to exercise
Low-exercisers required more motivating factors
to exercise, whereas high-exercisers reported more
factors that were non-influential to their exercise
behavior. The motivating factors that were shared
by the two groups again highlight how self-efficacy
should be harnessed for all of our PD patients;
both low- and high-exercisers were motivated by a
significant other, a personal trainer, or even their
Neurologist telling them it was necessary to exercise, all clearly strategies that can guide PD patients
to higher levels of self-efficacy. Recommendations
to exercise likely need to be heard more than once,
and from multiple healthcare professionals includ-
Unlike the prior study by Ellis et al., our study
did not identify fear of falling, lack of time, and
low-outcome expectation as major barriers to exercise. Their cohort had more participants who had a
history of falling (50% in the non-exercise group)
and perhaps even more balance and gait dysfunction
and low-outcome expectation than our low-exercise
group (28.1%) [11]. Another possible explanation
for the different findings is that most subjects in our
low-exercise group were still doing some exercise,
and in fact, only 13 (12% of low-exercise group)
were not exercising at all. Those who exercise even
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M. Afshari et al. / Motivators and Barriers to Exercise in Parkinson’s Disease
1 or 2 hours per week may be noticing benefits, and
therefore may not identify low-outcome expectation
as a barrier. In the Ellis et al. study, “exercisers”
were defined differently, and were compared to “nonexercisers” rather than “low exercisers,” which might
account for differences in the results. High-exercisers
in our study were also significantly more likely to still
be employed, 36.7% versus 18.9% of low-exercisers
(p = 0.006). Since ‘lack of time’ was previously identified as a barrier, we may have expected employed
patients to be exercising less. This finding likely
speaks to the functional status of the participants
where the more elderly or disabled are less likely to
be working and also exercising. Similarly, we found
that high-exercisers were significantly more likely to
be living in a private home, 98.1% versus 86.8% of
low-exercisers (p = 0.002). Once again, this is likely a
reflection of their better overall functional status and
thus higher propensity to exercise.
We recognize the limitations of the study include
use of self-reported data and lack of objective measures of disease severity such as UPDRS and Hoehn
and Yahr staging, non-motor symptoms of mood,
fatigue, and sleep, exercise habits, and exact time
spent exercising. Since this is a cross-sectional study,
the conclusions are merely observational. While there
were similar rates of PD patients with a disease duration of >5 years as seen in Table 1, disease duration
was also not precisely accounted for in the interpretation of these findings. We acknowledge that we did
not use a validated survey to assess exercise barriers,
but such a survey specific to the PD population does
not exist. Including a validated survey such as the
“Self-Efficacy for Exercise Scale” could have been
useful in assessing the reliability of our data, but in
order to reduce the time to complete the survey we
did not include this [19]. Another limitation is that
subjects were categorized based on a 3-hour exercise cut-off, while AHA guidelines use 150 minutes.
Subjects were being asked to estimate their average
amount of exercise per week using recall. They were
not completing diaries or calculating actual minutes.
Since we did not expect that responders would be
specific enough to recall to the half hour, we tried to
make it easier by using 3 hours as a general cut-off. In
categorizing it this way we recognize that we falsely
categorize those who are exercising between 2.5–3
hours as “low-exercisers,” although we expect this
is a small group. The fact that hours are estimated
rather than calculated with diaries or actigraphy is
also a limitation. While assumptions are made about
differences in intensity of exercise between groups,
these were generalizations about types of exercise,
and intensity was not actually assessed. It should
be acknowledged that actual behavior is affected by
many variables like heredity, overall health, lifestyle,
and socioeconomic class which is not being assessed
in its entirety in this study. The purpose of this study
was to gather data from this unique patient population
regarding general exercise behavior, perceptions, and
preferences, and draw conclusions on factors influencing exercise adherence. Another limitation of our
study is that we did not inquire about apathy from our
participants, their caregivers, or their neurologists,
which could be another variable particular to PD that
could affect exercise perceptions and behavior.
Conclusions
Given the overwhelming evidence of the benefits
of exercise in PD and the vital role physicians play in
motivating behavior change, we believe our findings
represent essential knowledge for the management of
patients with PD. In our study, we found that highexercisers with PD were more likely to engage in
multi-modal exercise regimens and believed in the
impact of exercise on their motor symptoms, mood,
and sleep. Low-exercisers, however, needed more
motivation to overcome perceived barriers including
having no one to exercise with, fatigue, and depression. This information can guide the design of future
exercise interventions and studies for PD patients that
aim to increase compliance.
ACKNOWLEDGMENTS
The authors have no acknowledgements to
disclose.
CONFLICTS OF INTEREST
Dr. Afshari and Amy Yang have nothing to disclose. Dr. Bega has served as a consultant for Teva
Pharmaceuticals and Cynapsus Therapeutics, Inc. He
serves on the speaker’s bureau for Acadia Pharmaceuticals, Inc. He has received grant support from the
National Parkinson Foundation.
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