The Impact of COVID-19 on Community-Based Exercise Classes for People with Parkinson Disease

Abstract Objective The purpose of the study was to determine the impact of COVID-19 restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors. Methods Data were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class ≥1/week for ≥3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire (GLT-Q), Self-Efficacy for Exercise (SEE) scale, Schwab-England scale, and Parkinson’s Disease Questionnaire 8 (PDQ-8). Results Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and PDQ-8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns and 54% reported leaving home ≤1/week. While 77% of the PD group scored “active” on the GLTQ, the mean SEE score (55 [24]) indicated only moderate exercise self-efficacy, and > 50% reported decreased exercise quantity/intensity compared to pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group). Conclusions During COVID-19 there has been less in-person and more virtual exercise class participation in people with PD, and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization. Impact As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD. Lay Summary During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD—and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction.

Results. Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and PDQ-8 (21 [15]) scores indicated low-tomoderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns and 54% reported leaving home ≤1/week. While 77% of the PD group scored "active" on the GLTQ, the mean SEE score (55 [24]) indicated only moderate exercise self-efficacy, and >50% reported decreased exercise quantity/intensity compared to pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group).
Conclusions. During COVID-19 there has been less in-person and more virtual exercise class participation in people with PD, and decreased exercise quantity and intensity.
Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization.
Impact. As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD.

Introduction
Parkinson disease (PD) is a neurodegenerative movement disorder characterized by rigidity, bradykinesia, tremor, and postural instability. 1 Physical activity and exercise are essential complements alongside pharmacological treatment in the management of PD, as they can slow the progression of PD-related symptoms and improve quality of life. [2][3][4] Community-based exercise classes have become an important way for people with PD to engage in exercise and maintain physical activity, and have become increasingly popular options. 5 Nevertheless, people with PD still experience a number of barriers to exercise participation such as fear of falling, fatigue, depression, and lack of knowledge on modifying exercise for PD-related symptoms. [6][7][8] Since the beginning of the novel coronavirus 2019 (COVID-19) pandemic additional barriers for participation in physical activity and exercise have appeared such as stay-at-home orders, gym closures, social distancing recommendations, and the cancellation of community-based exercise classes. [9][10][11] In addition, people with PD often fall into the "high-risk group" for developing severe COVID-19 symptoms because of age and potential comorbidities, and for much of the pandemic have been advised to limit activities outside of their home. 12 Therefore, the primary objective of this study was to determine current selfreported physical activity and exercise participation levels in people with PD who regularly participated in community-based exercise classes prior to COVID-19. An electronic survey was completed by people with PD and exercise class instructors in order to determine self-reported changes in exercise class participation and formats (inperson or virtual), and identify current critical environmental, social, and motivational barriers and related to exercise participation. We hypothesized that people with PD would report decreased physical activity levels since COVID-19 restrictions started and that both the PD and instructor groups would report similar changes in class formats, but that each group would have unique barriers, facilitators, and needs for exercise class participation.

[H1] Methods
This cross-sectional study used anonymous electronic surveys to gather data from people with PD and class instructors. All participants completed electronic consent and self-screening questions. Participants with PD confirmed the following inclusion criteria: Separate surveys for people with PD and exercise instructors were used. Both surveys used a combination of Likert scale and multiple choice closed-ended questions to identify current modifications to exercise class participation and format due to COVID-19 restrictions, general knowledge of COVID-19 restrictions, and overall adherence to these restrictions. Both groups were then asked to identify current environmental, social, and motivational barriers, facilitators, and needs for in-person and virtual class formats. The people with PD were also asked about current barriers, facilitators, and needs for general (ie, overall) exercise participation; and to report changes in their exercise frequency and intensity compared to pre-COVID levels. Finally, the following demographic data were reported physical activity and exercise participation and classifies individuals into one of three categories: 1) Active, 2) Moderately Active, or 3) Insufficiently Active. 16 The SEE is a reliable and valid scale that assesses perceptions about ability to participate in at least 20 minutes of moderate physical activity 3x per week. 17 The Schwab-England is a commonly used, reliable and valid scale that measures self-reported disability in people with PD via questions about ability to perform activities of daily living. 18 Finally, the PDQ-8, a validated self-report assessment of quality of life in people with PD, was used to further characterize the people with PD. 19,20 [H2] Data Analysis Descriptive statistics were used to characterize the data and describe the sample characteristics, activity levels in the PD group, and class format changes in both groups.
Narrative summary was used to compare difference in barriers, facilitators, and needs of class participants and instructors. All analysis was performed using SPSS Statistics 27 (IBM, Armonk, NY, USA). [ Caucasian, and 92% as non-Hispanic. The majority of people with PD (57%) were diagnosed over 5 years ago (n = 38). Mean Schwab-England score was 84.0 (15.7), mean PDQ-8 score was 21 (14.6), and mean SEE score was 55.0 (23.5). Fifty-five percent reported at least one fall in the past 12 months (Table 1). In the instructor group, 85% identified as female, 93% as Caucasian, and 91% as non-Hispanic. The majority (63%) had been teaching 1-5 years, came from a variety of professional backgrounds, and 79% had PD-specific exercise training ( Table 2).

[H2] COVID-19 knowledge and behaviors in PD and Instructor Groups
Almost all of the people with PD were aware of their local COVID-19 restrictions (93%) and the remainder reported being "somewhat aware" (7%). All of the instructor group (100%) reported being aware of their local COVID-19 restrictions. In the PD group, 23% had one or more medical comorbidities for developing severe illness from COVID, 10 compared with 9% in the instructor group. Only 2 people with PD (2%) and 4 instructors (9%) had a known positive COVID test.
In the PD group, 95% of respondents were at least a "little concerned" about their own COVID-19 exposure compared to 77% of the instructor group. Similarly, regarding their household's COVID-19 exposure, the PD group (94%) and the instructor group (93%) were at least a "little concerned". Finally, 95% of the instructor group was at least a "little concerned" about COVID-19 exposure for their class participants. Fifty-four percent of the PD group reported leaving home weekly or less, while 74% of the instructor group reported leaving home at least once a day. The top reasons why the PD group left home were to attend to essential activities such as medical appointments (85%) and shopping (77%), and for the instructor group it was for shopping (88%) and work (74%). Very few people in either group reported leaving the home for non-essential activities. Table 3 details COVID-19 related concerns and behaviors for both groups.

[H2] Barriers, Facilitators, and Needs in PD and Instructor Groups
The PD group reported their top general barriers for exercise during COVID-19 were feeling less motivated (37%) and having more fatigue (24%). Their top facilitators for continuing any form of exercise during COVID-19 were having an independent home exercise program (35%) and more time to exercise (23%). Despite having more time, and some independent resources, participants with PD still indicated they needed help to stay motivated (28%) and a place to exercise safely (22%).   Figure 3a details barriers, facilitators, and needs for the PD group, and Figure   3b for the instructor group. Supplementary material details all barriers, facilitators, and needs for both groups.

[H1] Discussion
This study determined that in people with PD who regularly participated in The PD group in this study were all attending exercise classes at least 1x/week for at least 3 months prior to when the COVID-19 restrictions began in the US (March 2020).
Therefore, it may not be surprising that their current mean Schwab-England score indicated relatively low disability (functional independence but with slowness).
Furthermore, the mean PDQ-8 scale of 21 is consistent with Hoehn & Yahr I-II, 19 further confirming the low-to-moderate level of disability in this sample. Considering their pre-COVID level of exercise engagement, it also was not surprising that the majority of the PD group was currently considered "active" on the GLT-Q. 16 However the majority did report a decrease in intensity and frequency of activity compared to pre-COVID, and their current mean SEE scores indicated only moderate confidence to overcome exercise and activity barriers. 17 Furthermore, the top general barriers to exercise for the PD group were increased fatigue and decreased motivation, which can both influence exercise selfefficacy. 8,21 Due to the cross-sectional nature of this study, change in GLT-Q, SEE, fatigue, and motivation are unknown. However, given that this group exercised regularly prior to COVID-19, it is plausible that COVID-19 created new barriers of fatigue and decreased motivation which influenced self-efficacy and therefore lowered exercise frequency and intensity.
The top barrier for attending in-person classes for both the PD and instructor groups was concern of COVID-19 exposure for the people with PD. Given that many people with PD in this study were over 65, and over 20% had at least one medical risk factor for developing severe COVID-19 symptoms, it follows that they were carefully following COVID-19 precautions by their infrequently leaving home, especially for nonessential and/or social activities. These findings are supported by Feeney et al, who reported people with PD were commonly cancelling non-essential activities due to a fear of COVID-19 exposure. 14 Even as restrictions ease, and more people get vaccinated, it is important for clinicians to realize that people with PD overall may be apprehensive about returning to in-person exercise and may need assurance that they will be safe.
In the current study, there was a marked increase in virtual class participation and instruction for the PD and instructor groups, respectively. The rate of current virtual class attendance in this study (64%) is similar to a recent study by Feeney et al (2021) 14 that reported 58% of people with PD were attending virtual or wellness classes during the COVID-19 pandemic. Feeney et al (2021) 14 also reported that the majority of the people with PD reported they would continue with telehealth appointments in the future. Similarly, in the current study, the majority of both groups reported they would likely continue virtual exercise class after COVID-19 restrictions ended. However, while most of the PD group reported no barriers to virtual class, 95% of instructors reported at least one barrier.
Virtual classes may continue to be an important resource for people with PD, but instructors may perceive more barriers and therefore require more support, training, and/or resources in order to successfully instruct virtual classes.
The current study identified differences in the top barriers reported by the PD and instructor groups for virtual classes. The top barriers for virtual class participation in the PD group were lack of accountability and social interaction. In people with PD, social engagement has been previously linked to exercise enjoyment and cited as a motivator for exercise, 22 and accountability of peers and instructors has been found to be important for exercise class participation. 23 Meanwhile, top instructor barriers for participation in virtual classes were participant safety (eg, fall risk), followed by participant technology access and use. Safety is a concern for any virtually based exercise class, especially in people with PD where fall risk is high. 24 Consistent with prior literature, the current study found that over half the PD group reported falling at least once in the past year. 24

Ethics Approval
The study was approved by the Institutional Review Boards at the 2 respective study sites (University of Colorado Anschutz Medical Campus and Washington University in St. Louis).

This work was supported by a grant from the Colorado Clinical and Translational
Science Institute (NIH/NCATS UL1-TR001082, TL1-TR002535).