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doi: 10.2522/ptj.20120279
Originally published online January 3, 2013
2013; 93:628-636.PHYS THER.
Dibble
Earhart, Matthew P. Ford, K. Bo Foreman and Leland E.
Lisa E. Brown, James T. Cavanaugh, Gammon M.
Terry Ellis, Jennifer K. Boudreau, Tamara R. DeAngelis,
Disease
Barriers to Exercise in People With Parkinson
http://ptjournal.apta.org/content/93/5/628found online at:
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Barriers to Exercise in People With
Parkinson Disease
Terry Ellis, Jennifer K. Boudreau, Tamara R. DeAngelis, Lisa E. Brown,
James T. Cavanaugh, Gammon M. Earhart, Matthew P. Ford, K. Bo Foreman,
Leland E. Dibble
Background. Exercise is known to reduce disability and improve quality of life in
people with Parkinson disease (PD). Although barriers to exercise have been studied
in older adults, barriers in people with chronic progressive neurological diseases,
such as PD, are not well defined.
Objective. The purpose of this study was to identify perceived barriers to exer-
cise in people with PD.
Design. The study had a cross-sectional design.
Methods. People who had PD, dwelled in the community, and were at stage 2.4
on the Hoehn and Yahr scale participated in this cross-sectional study (N⫽260; mean
age⫽67.7 years). Participants were divided into an exercise group (n⫽164) and a
nonexercise group (n⫽96). Participants self-administered the barriers subscale of the
Physical Fitness and Exercise Activity Levels of Older Adults Scale, endorsing or
denying specific barriers to exercise participation. Multivariate logistic regression
analysis was used to examine the contribution of each barrier to exercise behavior,
and odds ratios were reported.
Results. Three barriers were retained in the multivariate regression model. The
nonexercise group had significantly greater odds of endorsing low outcome expec-
tation (ie, the participants did not expect to derive benefit from exercise) (odds ratio
[OR]⫽3.93, 95% confidence interval [CI]⫽2.08 –7.42), lack of time (OR⫽3.36, 95%
CI⫽1.55–7.29), and fear of falling (OR⫽2.35, 95% CI⫽1.17– 4.71) than the exercise
group.
Limitations. The cross-sectional nature of this study limited the ability to make
causal inferences.
Conclusions. Low outcome expectation from exercise, lack of time to exercise,
and fear of falling appear to be important perceived barriers to engaging in exercise
in people who have PD, are ambulatory, and dwell in the community. These may be
important issues for physical therapists to target in people who have PD and do not
exercise regularly. The efficacy of intervention strategies to facilitate exercise adher-
ence in people with PD requires further investigation.
T. Ellis, PT, PhD, NCS, Department
of Physical Therapy and Athletic
Training, Sargent College of
Health and Rehabilitation Sci-
ences, Boston University, 635
Commonwealth Ave, Boston, MA
02215 (USA). Address all corre-
spondence to Dr Ellis at:
tellis@bu.edu.
J.K. Boudreau, PT, DPT, Depart-
ment of Physical Therapy and Ath-
letic Training, Sargent College of
Health and Rehabilitation Sci-
ences, Boston University, and
Braintree Rehabilitation Hospital,
Braintree, Massachusetts.
T.R. DeAngelis, PT, DPT, GCS,
Department of Physical Therapy
and Athletic Training, Sargent
College of Health and Rehabilita-
tion Sciences, Boston University.
L.E. Brown, PT, DPT, NCS, Depart-
ment of Physical Therapy and
Athletic Training, Sargent College
of Health and Rehabilitation Sci-
ences, Boston University.
J.T. Cavanaugh, PT, PhD, Depart-
ment of Physical Therapy, Univer-
sity of New England, Portland,
Maine.
G.M. Earhart, PT, PhD, Program
in Physical Therapy, Washington
University in St Louis, St Louis,
Missouri.
M.P. Ford, PT, PhD, Department
of Physical Therapy, University of
Alabama at Birmingham, Birming-
ham, Alabama.
K.B. Foreman, PT, PhD, Depart-
ment of Physical Therapy, Univer-
sity of Utah, Salt Lake City, Utah.
L.E. Dibble, PT, PhD, ATC, Depart-
ment of Physical Therapy, Univer-
sity of Utah.
[Ellis T, Boudreau JK, DeAngelis
TR, et al. Barriers to exercise in
people with Parkinson disease.
Phys Ther. 2013;93:628–636.]
© 2013 American Physical Therapy
Association
Published Ahead of Print:
January 3, 2013
Accepted: December 18, 2012
Submitted: July 9, 2012
Research Report
Post a Rapid Response to
this article at:
ptjournal.apta.org
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Exercise decreases disability and
improves quality of life in peo-
ple with Parkinson disease
(PD).
1,2
Studies have revealed that
gait, balance, strength, flexibility,
and cardiovascular fitness improve
in people who have PD and partici-
pate in exercise.
3–8
Advances in
medical management have resulted
in increased survival of people with
PD; therefore, management of this
disease and related sequelae must
occur over the course of many
years.
9–11
Although the short-term
benefits of exercise are well docu-
mented, the long-term benefits of
exercise for people with PD are
not well established.
12
Sedentary
lifestyles and limited adherence to
continuous exercise contribute to
the challenges of evaluating the long-
term benefits of exercise in people
with PD.
13,14
Understanding the fac-
tors that limit sustained participation
in exercise over the long term is
essential to understanding the poten-
tial of continuous exercise to miti-
gate disability in people with PD.
Adhering to exercise on a continu-
ous basis is a widespread challenge
for older adults who are healthy as
well as for older adults who have
chronic disabilities and live in the
community. Researchers have exam-
ined many factors that may influence
exercise adherence in older adults
and have identified the term “moti-
vators” to describe factors that pro-
mote adherence and the term “barri-
ers” to describe factors that limit
adherence. For older adults, per-
ceived barriers to exercise are more
predictive of exercise behavior than
perceived motivators.
15,16
In a study
examining exercise adherence dur-
ing outpatient physical therapy, 60%
of people who did not show exer-
cise adherence but only 13% of peo-
ple who did show exercise adher-
ence reported at least 1 barrier to
exercise.
16
Well-documented per-
ceived barriers to exercise in older
adults include lack of interest, poor
health, weakness, fear of falling,
pain, bad weather, lack of time, and
limited access to exercise
resources.
15,17,18
In addition, an asso-
ciation between low outcome
expectation from exercise (ie, peo-
ple did not expect to derive benefit
from exercise) and poor exercise
adherence was demonstrated in
older adults who had impaired bal-
ance and were discharged from
physical therapy.
15
Furthermore,
reports have shown that participa-
tion in regular physical activity
declines with increasing age and that
women who are more than 65 years
old participate less than men in that
age group.
17,19
Perceived barriers to exercise also
vary by age group. Younger adults
most commonly report lack of time
as the main perceived barrier to reg-
ular physical activity and exercise,
whereas older adults frequently indi-
cate poor health.
15,17,20
Schmidt et
al
21
described a community exercise
intervention for people 70 years of
age or older in which participants
who dropped out of the program
early were distinguishable from par-
ticipants who dropped out later or
completed the program. Participants
who dropped out early were charac-
terized by poorer perceived health
status, poorer physical performance,
and greater disease burden (particu-
larly musculoskeletal problems)
than participants who dropped out
later.
21
It appears that people who
may benefit most from exercise have
more difficulty adhering to regular
exercise over time.
22
Few studies have examined barriers
to exercise in people with neurolog-
ical disorders. Whereas O’Neill and
Reid
23
reported that 87% of 199
older adults who were healthy had at
least 1 perceived barrier to exercise,
Rimmer et al
24
found that nearly 50%
of 83 adults with unilateral stroke
reported at least 5 perceived barriers
to exercise. The 5 most common
perceived barriers for these adults
with stroke were the cost of a health
promotion program, lack of aware-
ness of a nearby fitness center, lack
of transportation, lack of knowledge
of how to exercise, and lack of
knowledge of where to exercise.
24
In a study of 93 people with multiple
sclerosis, items related to physical
exertion (eg, “exercise tires me” and
“exercise is hard work for me”) were
the most highly ranked barriers to
participation in exercise.
25
Ablah et
al
26
examined barriers to exercise in
adults with epilepsy and found that
the most common perceived barriers
were lack of motivation, personal
safety concerns, insufficient time,
lack of an exercise partner, exces-
sive pain, lack of transportation, side
effects of medication, fear of sei-
zures, and limited access to exercise
facilities. These adults experienced
many of the same barriers as adults
who were healthy in addition to bar-
riers that were disease specific.
26
Little is known about barriers to
exercise in people with PD.
Although people with PD may have
barriers to exercise in common with
older adults who are healthy, some
barriers may be more relevant than
others. For example, fear of falling
may be an important barrier to exer-
cise because previous studies
revealed an association between
restricted activity and fear of falling
in people with PD.
14,27,28
In addition,
given the progressive nature of the
disease and the associated decline in
physical function, people with PD
may not expect to derive benefit
from exercise (low outcome expec-
tation).
29
Furthermore, exercise is
Available With
This Article at
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•Discussion Podcast with Jennifer
Brach and author Terry Ellis.
Moderated by Kathleen Gill-Body.
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not routinely recommended by neu-
rologists for people with PD early in
the course of the disease; this factor
further limits perceptions regarding
the value of exercise in improving
outcomes.
30
A lack of a patient-
centered approach to prescribing
exercise may further limit motiva-
tion and outcome expectations.
31
The purpose of the present study
was to identify barriers to exercise in
people who have PD and dwell in
the community. On the basis of our
review of the literature, in addition
to studies indicating that perceived
barriers are more predictive of exer-
cise behavior than perceived motiva-
tors in older adults, we hypothesized
that low outcome expectation from
exercise and fear of falling would
distinguish people who have PD and
do not engage in long-term, contin-
uous exercise from those who have
PD and exercise regularly. Given
that previous research identified age
and sex as factors influencing partic-
ipation in exercise among older
adults,
17,19
we conducted secondary
analyses to determine whether these
factors were important to consider
in people with PD. In addition, given
that people with PD tend to become
less active with increasing disease
severity,
14
we examined whether
disease severity influenced the deter-
mination of barriers to exercise.
Knowledge of modifiable, perceived
barriers to exercise could help phys-
ical therapists develop strategies to
promote long-term adherence to
exercise in people with PD.
Method
Study Design and Population
In a parent longitudinal study, the
2-year trajectory of disablement in a
cohort of people with PD was inves-
tigated. Participants were examined
every 6 months over a 2-year period.
The present study consisted of a
cross-sectional analysis of the base-
line data from 260 participants in the
parent longitudinal investigation.
32
Baseline data were collected at 4 out-
patient settings between July 2009
and July 2010. Participants were
recruited from movement disorders
clinics and local support groups at
Boston University, University of
Utah, Washington University in St
Louis, and the University of Alabama
at Birmingham. All participants met
the following inclusion criteria: diag-
nosis of idiopathic PD, as defined by
the UK Brain Bank Criteria
33
; stages 1
to 4 on the modified Hoehn and
Yahr scale (H&Y)
34
; age of 40 years or
older; Mini-Mental State Examination
score of 24 or greater out of 30
35,36
;
living in the community (not in an
institution); and able to attend assess-
ment sessions and provide consent.
Potential participants were excluded if
they had a diagnosis of atypical parkin-
sonism, were at H&Y stage 5, or had
previous surgical management of their
PD. All participants provided informed
consent.
All evaluators were provided with a
standard operating procedures man-
ual and an instructional video that
described the protocol for adminis-
tering and scoring each instrument
for 2 participants with PD. Evalua-
tors rated both participants on 2
occasions separated by 1 week.
Within-site and between-site coeffi-
cients of variation were calculated
for all instruments and ranged from
0.08% to 5%. Participants were
examined over a 2.5-hour period and
were tested while in the “on” medi-
cation state.
Outcome Variables
For the purpose of comparison, par-
ticipants were divided into an exer-
cise group and a nonexercise group,
as determined with the Stages of
Readiness to Exercise Question-
naire.
37
Internal consistency (0.76)
has been established, and this tool
was shown to reliably differentiate
people at different stages (F⫽36.57;
df⫽4,369; P⫽.001) of changes in
exercise behavior in a sample of
The Bottom Line
What do we already know about this topic?
Exercise is known to reduce disability and improve quality of life in
people with Parkinson disease. Many individuals with Parkinson disease,
however, do not adhere to exercise over the long-term, reducing the
potential benefit. Although barriers to exercise have been investigated in
adults who are healthy, little is known about the barriers to exercise in
people with Parkinson disease.
What new information does this study offer?
This study revealed that low outcome expectation of exercise, lack of
time to exercise, and fear of falling appear to be important barriers to
engaging in exercise among ambulatory, community-dwelling people
with Parkinson disease.
If you’re a patient, what might these findings mean
for you?
When developing your exercise program, your physical therapist can
target these barriers in order to help you engage in regular exercise.
Barriers to Exercise in People With Parkinson Disease
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adults who were healthy.
38,39
This
instrument includes 5 statements
describing exercise frequency and
ranging from “I currently do not
exercise, and I do not intend to start
exercising in the next 6 months” to
“I currently exercise regularly (3 or
more times per week for 20 minutes
or more each time) and have done
so for longer than 6 months.” Partic-
ipants selected the statement that
best described their exercise behav-
ior. Participants who indicated that
they had exercised at least 3 or more
times per week for 20 minutes or
more each time throughout the pre-
ceding 6 months or longer were
assigned to the exercise group, and
participants who reported that they
had not exercised regularly over the
preceding 6 months or had not exer-
cised at all were assigned to the non-
exercise group.
The exercise behavior designations
were validated on the basis of survey
data from the Physical Activity Scale
for the Elderly (PASE) and perfor-
mance data from the StepWatch 3
Activity Monitor (SAM) (Orthocare
Innovations, Mountlake Terrace,
Washington). The PASE is a self-
administered survey used to measure
physical activity levels (eg, sports, jog-
ging, swimming, strengthening and
endurance exercises) and durations of
leisure activity, household activity, and
work-related activity during the pre-
ceding 7-day period. The PASE has
been validated in people 65 years of
age or older.
40,41
The PASE scores
range from 0 to 360, with higher
scores indicating higher physical activ-
ity levels.
41
The SAM device is attached
to the ankle and captures free-living
ambulatory activity. It is able to detect
strides taken by the leg to which it is
attached on the basis of a combination
of acceleration, position, and timing.
The SAM has good test-retest reliability
(intraclass correlation coefficient⫽
.84) and 96% accuracy in older
adults
42,43
and people with PD.
44
A
subset of 100 participants wore the
SAM during customary activity, includ-
ing exercise, 24 hours per day for 7
consecutive days, except during
showering or swimming. Validation
procedures are further described
elsewhere.
32
Measures
Baseline characteristics, including
age, sex, ethnicity, duration of PD,
comorbid health conditions, work-
ing status, occurrence of falls (self-
report over preceding 6 months),
and H&Y stage, were collected
through self-report questionnaires,
participant interviews, and physical
examinations. The Geriatric Depres-
sion Scale (GDS) was used to identify
depression-related symptoms.
45
The
GDS is a 30-item self-report question-
naire developed to assess depression
in older adults. Scores range from 0
to 30, with higher scores indicating
more depression-related symptoms.
45
The barriers subscale of the Physical
Fitness and Exercise Activity Levels
of Older Adults Scale was used to
assess the participants’ perceived
barriers to regular exercise behav-
ior.
46
The test-retest reliability (.751,
P⬍.0001) and internal consistency
(alpha coefficient⫽.727) have been
established for this subscale in older
adults who are healthy.
46
The barri-
ers subscale includes 13 statements
(Tab. 1), and each statement is rated
on a 4-point Likert scale reflecting
how strongly a person agrees with
the statement, ranging from
“strongly agree” to “strongly dis-
agree.” Responses were dichoto-
mized as endorsed (“strongly agree”
or “agree”) or denied (“disagree” or
“strongly disagree”) and entered into
a logistic regression model.
Data Analysis
Descriptive statistics. The means
and standard deviations for age,
H&Y stage, duration of PD, number
of comorbidities, and GDS scores
were calculated, and the frequencies
(ie, percent occurrence) for sex,
ethnicity, working status, and occur-
rence of falls were determined to
describe the characteristics of the
total sample as well as the exercise
and nonexercise groups (ie, separate
groups). Two-tailed independent t
tests or chi-square tests were used,
as appropriate, to assess differences
between the 2 groups.
Determination of barriers to
exercise behavior. Univariate
logistic regression was used to exam-
ine the contribution of each poten-
tial barrier to exercise behavior for
the entire sample. A multivariate
logistic regression analysis was then
applied to examine the association
between barriers and exercise
behavior while controlling for
confounding variables. A backward
elimination procedure was used to
remove the least significant barriers
1 at a time until only barriers with
Pvalues of .05 or less remained.
Odds ratios were used to represent
the odds that a barrier would be
endorsed by the nonexercise group
compared with the exercise group.
Given that sex, age, and disease
severity have been shown to influ-
ence exercise behavior, we con-
ducted secondary analyses by using
an identical multivariate regression
analysis with a backward elimination
procedure for subsets of men,
women, participants less than 65 years
of age, participants 65 years of age or
older, participants in H&Y stages 0 to
2, and participants in H&Y stages 2.5
to 4.
14,15,17,19–21
Study data were man-
aged with the Research Electronic
Data Capture (REDCap) tools hosted
at the University of Utah.
47
All data
were analyzed with the statistical soft-
ware program SPSS 16.0 (SPSS Inc,
Chicago, Illinois).
Role of the Funding Source
Funding for this project was pro-
vided by the Davis Phinney Founda-
tion, the Parkinson’s Disease Foun-
dation, and NIH K12 Building
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Interdisciplinary Research in Wom-
en’s Health (HD43444).
Results
Exercise Behavior Designation
and Validation
Of the 260 participants, 164 (63%)
were assigned to the exercise group
and 96 (37%) were assigned to the
nonexercise group. These designa-
tions were validated by the PASE
scores, which were significantly
higher (P⫽.02) in the exercise
group, indicating a higher level of
physical activity during the week of
assessment (Tab. 2). Furthermore,
the SAM data showed that the exer-
cise group had a significantly higher
(P⫽.02) number of average steps
per day than the nonexercise group
(Tab. 2).
Sample Characteristics
The sample characteristics are
shown in Table 2. The sample
included 260 participants with pre-
dominantly mild to moderate disease
severity: 7.7% were considered to be
in H&Y stages 1 and 1.5, 66.4% were
in stages 2 and 2.5, 20.1% were in
stage 3, and 5.8% were in stage 4.
The exercise group had a signifi-
cantly shorter average disease dura-
tion (P⫽.02) and significantly lower
average GDS scores (P⫽.00) than
the nonexercise group. The exercise
and nonexercise groups did not dif-
fer in age, sex, H&Y stage, number
of comorbidities, working status, or
number of participants who had
fallen.
Barriers to Exercise
In the univariate logistic regression
analysis (Tab. 1), 8 barriers—low
outcome expectation, tightness in
chest, lack of time, perceived health,
discomfort with exercise, depres-
sion, bad weather, and fear of fall-
ing—were significantly associated
with the nonexercise group. After
the multivariate regression analysis
with backward elimination, low out-
come expectation, lack of time, and
fear of falling remained in the final
regression model and were quanti-
fied as odds ratios (Tab. 1). The non-
exercise group had 3.93 times the
odds of endorsing low outcome
expectation as the exercise group. In
addition, the nonexercise group had
3.36 times the odds of endorsing
lack of time and 2.35 times the odds
of endorsing fear of falling as the
exercise group.
The percentages of the exercise and
nonexercise groups endorsing each
barrier are shown in Table 3. In the
secondary analyses, there were no
significant differences in barriers to
exercise across sex, age groups
dichotomized at 65 years, or disease
severity classified by H&Y stage.
Discussion
In the present study, we examined
perceived barriers to exercise in peo-
Table 1.
Regression Analysis
a
Barrier
Univariate Analysis Multivariate Analysis
b
OR 95% CI PAOR 95% CI P
I feel the same whether I am physically active or
not (low outcome expectation)
3.87 2.10–7.13 .00
c
3.93 2.08–7.42 .00
I am concerned that I will hurt or strain myself if I am too
physically active
1.53 0.84–2.80 .16
I sometimes get tightness in my chest when I exert myself 2.64 1.26–5.56 .01
c
I have too little time for exercise (lack of time) 3.66 1.75–7.63 .00
c
3.36 1.55–7.29 .00
I do not have the strength to exercise 1.85 0.84–4.07 .13
If my health were better, I would be more active 1.92 1.03–3.58 .04
c
I am not interested in exercise 1.98 0.91–4.32 .08
It is difficult to exercise when I ache 2.28 1.18–4.42 .01
c
It is difficult to exercise if I feel depressed 1.70 1.02–2.85 .04
c
Lack of transportation limits my exercise options 1.08 0.54–2.13 .84
Bad weather prevents me from exercising 1.90 1.10–3.30 .02
c
I sometimes get short of breath when I exercise 1.31 0.79–2.17 .30
Fear of falling prevents me from exercising (fear
of falling)
1.92 1.00–3.69 .05
c
2.35 1.17–4.71 .02
a
Odds ratio (OR) and adjusted odds ratio (AOR) describe the odds that a particular barrier would be endorsed by the nonexercise group compared with the
exercise group. Barriers (and data) in bold type distinguished the nonexercise group from the exercise group in the multivariate logistic regression analysis
with backward elimination. CI⫽confidence interval.
b
Data for items remaining in the final multivariate regression model are shown.
c
Barrier associated with the nonexercise group in the univariate logistic regression analysis.
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ple who had PD and dwelled in the
community by identifying the barri-
ers that distinguished participants
who engaged in regular exercise
(exercise group) from participants
who did not exercise regularly (non-
exercise group). Perceived barriers
that limited exercise participation
included low outcome expectation
from exercise, lack of time to exer-
cise, and fear of falling. These results
are in agreement with our hypothe-
sis identifying low outcome expecta-
tion and fear of falling as potential
barriers to exercise in people with
PD. Lack of time was also identified
as an additional important barrier
in the nonexercise group. These per-
ceived barriers to exercise are poten-
tially modifiable and important for
physical therapists to consider in
their treatment plans.
The most salient barrier identified in
the multivariate regression analysis
was low outcome expectation from
exercise. This concept was repre-
sented by the statement, “I feel the
same whether I am physically active
or not.” Participants who endorsed
this statement may not have per-
ceived a benefit of exercise, mani-
fested as a barrier to engaging in reg-
ular physical activity. Burton et al
48
examined factors associated with
performing “brisk physical activity,”
such as “walking briskly, gardening,
or heavy housework,” at least 3
times per week in older adults who
had PD and dwelled in the commu-
nity. Older adults who believed that
physical activity promoted better
health were more than twice as
likely to initiate physical activity.
48
Therefore, educating people about
the health-related benefits of exer-
cise is important and may alter exer-
cise outcome expectations.
20
Indeed,
many older adults who have PD may
lack knowledge of how exercise
could affect their symptoms—partic-
ularly in the context of a chronic
progressive neurological disease.
Other methods, in addition to educa-
tion, may further enhance outcome
expectations. For example, cognitive-
behavioral strategies targeting exer-
cise outcome expectations, such as
goal setting, feedback, and relapse
prevention training, have been
shown to increase regular exercise
participation in older adults more
than health education or exercise
instruction alone.
49
The extent to
which such strategies may be effec-
tive for people with PD warrants fur-
ther investigation.
Table 2.
Sample Characteristics
a
Characteristic
Total Sample
(Nⴝ260)
Exercise Group
(nⴝ164)
Nonexercise Group
(nⴝ96) P
Age, y, X (SD) 67.67 (9.2) 68.25 (9.3) 66.66 (9.0) .18
Sex, n (%) men 148 (56.9) 98 (59.8) 50 (52.1) .23
Ethnicity, white, n (%) white 239 (91.9) 153 (93.3) 86 (89.6) .29
H&Y stage, X (SD) 2.35 (0.7) 2.33 (0.6) 2.43 (0.7) .28
Disease duration, y, X (SD) 6.29 (4.8) 5.33 (4.1) 7.92 (5.3) .02
b
No. of comorbidities, X (SD) 1.54 (1.3) 1.55 (1.3) 1.52 (1.3) .87
GDS score, X (SD) 7.87 (5.8) 6.98 (5.5) 9.44 (5.8) .00
b
Working status, (%) retired 172 (66.2) 110 (67.1) 62 (64.6) .77
No. (%) of participants who had fallen 124 (47.7) 76 (46.3) 48 (50.0) .57
PASE score, X (SD) 142.62 (79.4) 118.93 (85.7) .02
b
SAM, steps/d,
c
X (SD) 9,202 (4,096) 7,360 (3,114) .02
b
a
H&Y⫽Hoehn and Yahr Scale, GDS⫽Geriatric Depression Scale, PASE⫽Physical Activity Scale for the Elderly, SAM⫽StepWatch 3 Activity Monitor.
b
Significantly different between the exercise group and the nonexercise group.
c
The SAM data were collected from a subset of 100 participants (73 in the exercise group and 27 in the nonexercise group).
Table 3.
Percentages of Participants in the Exercise and Nonexercise Groups Who Endorsed
Each Barrier
Barrier
% of Participants Who
Endorsed the Barrier
P
Exercise Group
(nⴝ164)
Nonexercise Group
(nⴝ96)
Low outcome expectation 13.4 37.5 .00
Lack of time 7.9 24.0 .00
Fear of falling 13.4 22.9 .05
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Perceived lack of time also was asso-
ciated with the nonexercise group.
People may be engaged in vocational
or social activities that take priority
over exercise. This barrier also may
represent a perceived lack of time
because of the cognitive changes
associated with PD. The lack of time
to exercise, identified in the present
study, may reflect difficulty prioritiz-
ing and planning daily activities.
Koerts et al
50
reported that people
with PD planned and executed por-
tions of a multitask test sequentially
rather than simultaneously, high-
lighting the limitations associated
with executive function. In a com-
munity sample of adults with long-
standing PD, more than 50% of the
adults had cognitive impairment, and
30% of those adults had a dominant
executive function impairment.
51
Like
low outcome expectation, lack of time
may be addressed with cognitive-
behavioral strategies, including priori-
tizing activities and scheduling exer-
cise as part of one’s daily routine, with
the assistance of caregivers for rein-
forcing these strategies.
52
Fear of falling, the third perceived bar-
rier associated with the nonexercise
group, was previously associated with
activity restriction in older adults who
were healthy as well as those with
PD.
27,53
Furthermore, people with PD
were shown to have more fear of fall-
ing than people who were
healthy.
54,55
Fear of falling has been
described as an independent risk fac-
tor for falls in people with PD.
55,56
Therefore, increasing postural stability
may not decrease a person’s fear of
falling, so that fear of falling must be
specifically addressed. Interventions
targeting fear of falling in older adults
have included education about a real-
istic self-assessment of the risk of fall-
ing and environmental safety factors,
risk-taking training to learn to seek
assistance in situations in which they
were fearful, and promotion of physi-
cal fitness.
53
One randomized con-
trolled trial demonstrated improve-
ments in fear of falling in people who
had PD and completed an 8-week
exercise program including incremen-
tal speed-dependent treadmill train-
ing.
57
Experiencing successful mobil-
ity during daily activities may build
confidence and reduce fear of
falling.
53
In addition to minimizing barriers
to exercise, interventions may also
focus on increasing people’s ability
to successfully exercise even in the
presence of barriers. Our results
revealed that although a greater per-
centage of participants in the non-
exercise group endorsed low out-
come expectation, lack of time, and
fear of falling than participants in
the exercise group, some partici-
pants in the exercise group (albeit
fewer) also endorsed these barriers
but still managed to successfully
engage in regular exercise. Previous
research identified an association
between self-efficacy and participa-
tion in exercise in the general popu-
lation, in people with chronic disabil-
ities, and in people with PD.
18,58,59
Self-efficacy related to exercise refers
to people’s judgment of their capa-
bility to exercise successfully.
60
Peo-
ple with high self-efficacy are more
likely to engage in exercise even in
the presence of perceived barriers.
25
Behavioral change interventions tar-
geting self-efficacy (eg, goal setting,
overcoming barriers to exercise,
social support, and monitoring prog-
ress) have been shown to increase
physical activity in people with
chronic disabilities, such as multiple
sclerosis,
61
and show promise as
potential effective interventions in
people with PD.
62
Other studies of
people with PD have suggested
that a patient-centered approach, in
which therapists work in partner-
ship with people to facilitate a better
understanding of the goals and out-
comes expected from exercise, also
may help to increase self-efficacy.
31,63
The results of the present study may
have been influenced by differences
in the characteristics of the exercise
and nonexercise groups. For exam-
ple, the nonexercise group had a lon-
ger duration of PD; however, disease
severity, as measured by H&Y stage,
did not differ between the exercise
group and the nonexercise group.
In addition, the nonexercise group
had higher GDS scores, suggesting a
greater prevalence of depression in
the nonexercise group than in the
exercise group. However, the GDS
scores of both groups were below
the point range associated with mild
to moderate depressive symptoms
in people with PD.
64
Disease severity
and depression were assessed indi-
rectly in the logistic regression anal-
ysis by the respective barriers “If my
health were better, I would be more
active” and “It is difficult to exercise
if I feel depressed.” Neither of these
barriers remained significant in the
multivariate analysis. Furthermore, our
secondary analyses did not reveal any
differences in barriers to exercise
according to sex, disease severity, or
age. These data suggested that low
outcome expectation, lack of time,
and fear of falling were important bar-
riers to exercise irrespective of sex,
age, or disease severity.
There are several limitations of the
present study. First, we are present-
ing the results of a cross-sectional
analysis; therefore, a causal relation-
ship between barriers to exercise
and exercise participation cannot be
assumed. Second, our participants
were predominantly white, had a
high socioeconomic status, were
healthy, and exercised; these factors
may limit the generalization of our
results. Although the nonexercise
group comprised 96 people, this
number represented only 37% of
our participants—a percentage con-
siderably lower than the 64% of
participants who had PD and were
sedentary in the ParkFit study.
65
Par-
ticipants in the present study tended
Barriers to Exercise in People With Parkinson Disease
634 fPhysical Therapy Volume 93 Number 5 May 2013
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to be active in the PD community,
having participated in local support
groups, wellness programs, or other
research activities; these factors may
have led to potential selection bias.
The proportion of people with PD
in the general population who do
not exercise likely is greater. Third,
assignment to the exercise group or
the nonexercise group was based on a
retrospective self-report scale; how-
ever, data from the PASE and SAM
were used to validate this distinction.
Fourth, we did not categorize whether
participants engaged in prescribed
exercise, self-directed exercise, or
group exercise. This distinction may
have influenced exercise behavior.
Most studies, including the present
study, have identified barriers to
exercise in a cross-sectional manner.
A distinction between barriers that
interfere with initiating exercise and
those that interfere with maintaining
exercise is often not made when a
behavior is observed at only 1 point
in time and previous exercise partic-
ipation is not clearly defined. It is
plausible that barriers that limit
sustained exercise in people who
already exercise may differ from
barriers that interfere with initiating
exercise. A recent study of people
with chronic health conditions
began to make this distinction and
explicitly set out to examine barriers
to maintaining exercise in people
who already engaged in regular exer-
cise.
66
Additional studies are needed
to examine this distinction further
to determine whether the targets of
interventions differ. Moreover, con-
trolled trials are needed to identify
the most effective intervention strat-
egies for reducing barriers to exer-
cise and for facilitating changes in
exercise behavior in people with PD
and in people with other chronic
disabling conditions.
Conclusions
Exercise is known to reduce disabil-
ity and improve quality of life in peo-
ple with PD. However, limited par-
ticipation in exercise reduces the
potential of continuous exercise to
mitigate disability in people with PD.
The purpose of the present study
was to identify barriers to exercise in
people who have PD and dwell in
the community. Our results revealed
that low outcome expectation from
exercise, lack of time to exercise,
and fear of falling were important
perceived barriers to engaging in
exercise in people who have PD, are
ambulatory, and dwell in the com-
munity. These may be important
issues for rehabilitation providers to
target in people who have PD and
are not exercising regularly.
Dr Ellis, Dr Cavanaugh, Dr Ford, Dr Foreman,
and Dr Dibble provided concept/idea/re-
search design. Dr Ellis, Dr Boudreau, Dr
Cavanaugh, Dr Ford, Dr Foreman, and Dr
Dibble provided writing. All authors pro-
vided data collection. Dr Ellis, Dr Boudreau,
Dr Ford, and Dr Foreman provided data
analysis. Dr Ellis, Dr DeAngelis, Dr Foreman,
and Dr Dibble provided project manage-
ment. Dr Ellis, Dr Ford, Dr Foreman, and Dr
Dibble provided fund procurement. Dr Ellis,
Dr DeAngelis, Dr Earhart, Dr Foreman, and
Dr Dibble provided study participants. Dr
Ellis, Dr Earhart, Dr Ford, Dr Foreman, and
Dr Dibble provided facilities/equipment.
Dr Ford provided institutional liaisons. Dr
DeAngelis provided clerical support. Dr
DeAngelis, Dr Earhart, Dr Foreman, and Dr
Dibble provided consultation (including
review of manuscript before submission).
This study was approved by the institutional
review boards of all of the institutions.
This work was previously presented in a
Poster Presentation titled “Barriers to Exer-
cise in Persons with Parkinson Disease” at the
American Physical Therapy Association Com-
bined Sections Meeting; February 11, 2012;
Chicago, Illinois.
Funding for this project was provided by the
Davis Phinney Foundation, the Parkinson’s
Disease Foundation, and NIH K12 Building
Interdisciplinary Research in Women’s
Health (HD43444).
DOI: 10.2522/ptj.20120279
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636 fPhysical Therapy Volume 93 Number 5 May 2013
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doi: 10.2522/ptj.20120279
Originally published online January 3, 2013
2013; 93:628-636.PHYS THER.
Dibble
Earhart, Matthew P. Ford, K. Bo Foreman and Leland E.
Lisa E. Brown, James T. Cavanaugh, Gammon M.
Terry Ellis, Jennifer K. Boudreau, Tamara R. DeAngelis,
Disease
Barriers to Exercise in People With Parkinson
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