Increasing exercise with a mobile app in people with Parkinson’s disease: a pilot study

Introduction

Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterised by bradykinesia, rigidity, resting tremor, postural instability, and gait disturbance. These symptoms significantly diminish the quality of life (QoL) of those affected. Pharmacological and surgical interventions are often employed to manage the disease. Recent evidence suggests that exercise plays a crucial role in alleviating symptoms and improving overall well-being in people with PD (Mak et al. 2017). However, numerous barriers often prevent people with PD from participating in traditional face-to-face exercise programs. These barriers include physical discomfort, non-motor symptoms, poor accessibility of exercise locations, transportation issues, discomfort in crowded spaces, and financial burden (Schootemeijer et al. 2020). The COVID-19 pandemic has intensified these challenges. This situation underscores the pressing need for more accessible exercise alternatives for people with PD (Song et al. 2020; Langer et al. 2021).

In response to these challenges, various methods and technologies have been explored to facilitate exercise and rehabilitation for people with PD, including community-based resources, virtual reality, telerehabilitation, and motivational tools (Langer et al. 2021; Lau et al. 2021). Mobile apps are increasingly being recognised as valuable tools for motivating individuals with osteoarthritis and knee pain (Danbjørg et al. 2018; Shah et al. 2023). Furthermore, they can offer personalised exercise programs tailored to the specific needs of people with PD, enhancing accessibility (Linares-Del Rey et al. 2019). However, there remains limited scientific evidence on the effectiveness of mobile apps in increasing exercise levels and improving the QoL for individuals with PD (Langer et al. 2021).

To bridge this gap in the literature, we designed a mobile app with a specialised home-based exercise program for people with PD. We investigated whether the app effectively improves physical activity in people with PD, focusing on its potential to reduce barriers, such as poor accessibility to exercise locations, transportation issues, and financial burden.

Methods

Mobile app, home-based exercise program, and motivational strategies

The app and home-based exercise program were specifically developed for people with PD and the present study. To motivate exercising, we designed a free mobile app for the present study. The application included (1) a home-based exercise program that does not require any special tools; (2) in-app notifications, which are messages that a researcher can deliver to users to remind them to use the app and perform exercise every morning on weekdays; (3) in-app compliments when the participants performed their exercises; and (4) a tracking system for the number of times the participants have exercised in the last week, last 2 weeks, and last month. The home-based exercise program for PD was developed by professional exercise instructors (H. Y. Kim) and movement specialists (J. W. Cho, J. Youn, and J. H. Ahn). The exercise videos were filmed, and 21 exercise videos were developed. Each video lasted approximately 15–20 min. The program included moderate-intensity exercises: sitting in the right position; walking with the right posture; and stretching and strengthening exercises for the neck/shoulder, back, legs/knees/ankles, and hands/wrists.

The mobile app is available for Android (https://play.google.com/store/apps/details?id=com.movement.PDexercise) or as a progressive web app (https://previewer.adalo.com/594d5e06-c8c9-4ee0-94d5-e0ef4668c8a6). The app was made in Korean, and only designated users were allowed access to the username and password created for each participant. Prior to beginning the exercise program, participants received a 30-min training session that covered how to use and record their exercises using the app. Additionally, we gave each participant a printed manual for reference. They also learned how to answer follow-up assessments embedded in the app. Participants could login to the app with their username and password and select 1 of the 21-exercise videos on the home screen. If they touched a selected video, the screen was connected to the exercise video screen (Fig. 1). The participants could watch a video or switch to another video. Below the video, a brief description of the exercise was provided. Participants could record their exercise by touching the ‘exercise done’ button at the bottom of the screen. The records were automatically recorded on a web-based database, and only the user who recorded them and the researcher could see the personal records. The compliance of each participant was investigated through these self-reported records. Participants can track the number of times they have exercised since the last week, last 2 weeks, and last month. The in-app alarm went off every weekday morning to remind the participants to use the app and perform exercise.

Fig. 1.

The home screen, exercise video screen, tracking system and search system screen of the app.

Results

A total of 41 patients were recruited, of whom 25 completed the 2-week program and 16 did not (Fig. 2). The demographic and clinical characteristics are described in Table 1. The median number of exercises completed by the participants was 26.0 with an IQR of 14.5–34.0. The median MET-min/week significantly increased from 1386.0 to 3210.0 MET-min/week (P = 0.009), especially in the moderate-intensity (P = 0.049) and walking activities (P = 0.002) but not in the vigorous-intensity activity (P = 0.306, Fig. 3a). The PDQ-39 SI also improved after the 2-week program, especially in terms of activities of daily living (ADL), emotional well-being, cognition, communication, and bodily discomfort (Table 2 and Fig. 1). Correlation analysis showed that the number of completed exercises exhibited positive correlation with change of moderate (P = 0.016, r = 0.477), walking (P = 0.033, r = 0.428) and total MET-min/week (P = 0.009, r = 0.511) but not with vigorous exercise (P = 0.101, r = 0.336, Fig. 3c). The results of our study indicate that there was no correlation between the decrease of PDQ-39 SI and the number of completed exercises or MET-min/week. In the user satisfaction survey, 96.2 and 84.6% of the participants reported that they were satisfied with the app and exercise programs, respectively (Supplementary Table S2). No participants reported any adverse events while using the app (Supplementary Table S2).

Fig. 2.

Diagram showing the study flow.

Fig. 3.

(a) After the 2-week program, there was a significant increase in MET-min/week as measured by the IPAQ-SF, particularly in moderate-intensity exercise and walking as well as change in the PDQ-39 SI and subdomains. (b) Activities of daily living, emotional well-being, cognition and communication, and bodily discomfort after 2 weeks of study (light grey) improved compared to baseline assessments (dark grey). (c) Correlation analysis showed that the number of completed exercises exhibited positive correlation with change of moderate, walking, and total MET-min/week but not with vigorous exercise. IPAQ-SF, International Physical Activity Questionnaire-Short Form; PDQ-39 SI, Parkinson’s Disease Questionnaire-39 Summary Index; T1, baseline; T2, after 2 weeks. An asterisk (*) in the figure indicates statistical significance (P < 0.05).

We compared the clinical features of the participants who completed the program and those who dropped out. There were no differences in the mean age, disease duration, UPDRS-III, or PDQ-39. MET-min/week showed no difference regardless of activity intensity (Supplementary Table S1). However, dropout participants did report lower confidence in using a smartphone, especially with questions 10 and 12 (Table 1).

Discussion

The main objective of the present pilot study was to evaluate the effectiveness of the exercise app in increasing the amount of exercise performed by individuals with PD. The findings indicated that the use of the exercise app can be a valuable tool in enhancing physical activity levels among the people with PD. The overall physical activity of the participants increased, especially for moderate-intensity and walking activities. Moreover, as the amount of exercise increased, the participants’ QoL improved.

Most participants were satisfied with the app and the included exercise videos; consequently, the app successfully helped increase the amount of exercise. As the exercise programs included in the app were of moderate intensity, it is expected than an the observed increase in moderate-intensity activity was expected. However, the results also showed an increase in walking activity, suggesting that the app can motivate general physical activity beyond the guided exercises. Additionally, our findings demonstrated a positive correlation between the number of completed exercises and an increase in MET-min/week, particularly moderate and walking activity, further indicating the app’s effectiveness in promoting physical activity. There are various motivating tools that could make can encourage people with PD to engage in exercise, including social support, feedback on performance, professional support, education about benefits of exercise, and recommendation of exercise by a neurologist (Schootemeijer et al. 2020). We tried to provide several motivators to help participants start and remain engaged in exercise, including supplying the app and the home-based exercise program, in-app alarms, providing complimentary messages, and providing a tracking system; participating in the study itself was also one of the motivating factors. Our results suggest that using the app is useful to motivate and encourage exercise. However, there is a possibility of selection bias due to the nature of using a smartphone app as the intervention. Patients who are not technologically literate or have difficulty using smartphones may have been less likely to participate in the study, resulting in a potentially more tech-savvy sample than the general PD population. Additionally, dropouts who were unsatisfied with the app or lacked confidence in using a smartphone may have also contributed to selection bias.

The QoL of the participants also improved, especially in regards to the domains of ADL, emotional well-being, cognition, communication, and bodily discomfort, but not mobility. This suggests that exercise interventions are effective at improving the overall QoL of people with PD (Chen et al. 2020). A previous study by Goodwin et al. (2008) showed that physical activities and exercises correlate with improved QoL in people with PD. Given the complexity and multifactorial nature of QoL, other factors, such as depression and anxiety, could significantly influence the observed QoL enhancements (Soh et al. 2011). Hence, long-term exercise programs and investigations of other factors, such as depression and anxiety, are necessary to determine their effect on QoL of PD patients.

The study has several limitations that should be considered when interpreting its findings. First, the study only included patients with a H&Y stage 3 or less to minimise the risk of falls or trauma, which may limit the generalisability of the results to the entire PD population, particularly those with advanced PD. Moreover, the small number of participants warrants caution in interpreting the results. Further research is needed to investigate the effectiveness and safety of the exercise program in a broader population of people with PD. Second, the study did not investigate mood symptoms, such as depression or anxiety, which could affect physical activity and potentially impact the dropout rate of the study. These factors may have important roles in the success of exercise interventions and should be explored in future research to determine their impact on outcomes. Third, this study experienced a substantial dropout rate of 39.0%, suggesting that our findings might not be universally applicable to all individuals with PD, especially those unfamiliar with smartphone use. Lastly, the 2-week study duration was too short to accurately reflect the actual effects on motor symptoms, QoL, and the long-term benefits of using the app.

This study exhibited a higher rate of dropouts than expected (39.0%), which is similar to that of the previous study using a paid exercise app (Landers and Ellis 2020). In our study, the reason the dropouts did not use the app is unclear, as they did not answer the user satisfaction survey. There were no differences in the baseline amount of exercise, demographic characteristics, or disease-related factors between the participants who completed the program and those who dropped out. Considering that the median number of completed exercises in the dropouts was two, there may have been dissatisfaction with the app or the exercise program, or there may have been difficulties in using it. The lower confidence in using smartphones reported by dropouts provides support for the latter explanation.

Several recommendations can be made from the findings and limitations of the present study. First, a user-friendly and tailored interface for the target patients is required. Considering that most people with PD are elderly and unfamiliar with a mobile interface, a more intuitive interface is needed. Second, it is necessary to educate participants regarding the use of an app and e-health literacy. Despite the growing importance of e-health literacy (van Olmen 2022), the e-health literacy of people with PD has not been accurately studied. Further research on the status of e-health literacy and education in insufficient areas is required. Finally, providing a real-time exercise program and various levels of exercise programs would be helpful for the remaining participants, ensuring the accuracy of their exercises and monitoring the risk of injury.

In conclusion, the present study showed that an app providing a home-based exercise program was a useful tool for improving the amount of exercise and QoL of people with PD. To maximise the effect of the app, education regarding e-health literacy, improvement in the quality of the app, and diversification of the exercise program should be considered in future studies.

Supplementary material

Supplementary material is available online.