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Original Article
Effectiveness of Live-Streaming Tele-Exercise Intervention in Patients With Parkinson’s Disease: A Pilot Study
Jongmok Ha1,2orcid, Jung Hyun Park3orcid, Jun Seok Lee1,2orcid, Hye Young Kim4orcid, Ji One Song1orcid, Jiwon Yoo1orcid, Jong Hyeon Ahn1,2orcid, Jinyoung Youn1,2,3orcid, Jin Whan Cho1,2,3corresp_iconorcid
Journal of Movement Disorders 2024;17(2):189-197.
DOI: https://doi.org/10.14802/jmd.23251
Published online: February 29, 2024

1Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

2Neuroscience Center, Samsung Medical Center, Seoul, Korea

3Sungkyunkwan University School of Medicine, Suwon, Korea

4Age Well Fitness Training Center, Seoul, Korea

Corresponding author: Jin Whan Cho, MD, PhD Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea / Tel: +82-2-3410-1279 / Fax: +82-2-3410-0052 / E-mail: jinwhan.cho@samsung.com
• Received: November 29, 2023   • Revised: February 1, 2024   • Accepted: February 29, 2024

Copyright © 2024 The Korean Movement Disorder Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objective
    Exercise can improve both motor and nonmotor symptoms in people with Parkinson’s disease (PwP), but there is an unmet need for accessible and sustainable exercise options. This study aimed to evaluate the effect, feasibility, and safety of a regularly performed live-streaming tele-exercise intervention for PwP.
  • Methods
    A live-streaming exercise intervention for PwP was implemented twice a week for 12 weeks. We measured the motor and nonmotor symptom scores of the included patients before and after the intervention. Changes in clinical scores from baseline to postintervention were analyzed using paired t-tests. Factors associated with improvements in clinical scores and compliance were analyzed using Pearson’s correlation analysis.
  • Results
    Fifty-six participants were enrolled in the study. There were significant improvements in Hospital Anxiety and Depression Scale (HADS)-anxiety (p = 0.007), HADS-depression (p < 0.001), Unified Parkinson’s Disease Rating Scale (UPDRS) part III (p < 0.001), UPDRS total (p = 0.015), Hoehn and Yahr stage (p = 0.027), and Parkinson’s Disease Fatigue Scale-16 (p = 0.026) scores after the intervention. Improvements in motor symptoms were associated with improvements in mood symptoms and fatigue. Higher motor impairment at baseline was associated with a greater compliance rate and better postintervention composite motor and nonmotor outcomes (ΔUPDRS total score). Overall, the 12-week tele-exercise program was feasible and safe for PwP. No adverse events were reported. The overall adherence rate was 60.0% in our cohort, and 83.4% of the participants were able to participate in more than half of the exercise routines.
  • Conclusion
    The live-streaming tele-exercise intervention is a safe, feasible, and effective nonpharmacological treatment option that can alleviate fatigue and improve mood and motor symptoms in PwP.
South Korea is projected to become a super-aged society by 2025 [1]. In South Korea, which is not exempt from the ongoing worldwide “Parkinson’s epidemic, [2]" the annual incidence of Parkinson’s disease (PD) has more than tripled in the last decade [3]. Moreover, the estimated nationwide prevalence is 13.9 per 100,000 person-years as of 2015 and is steadily increasing, affecting the full breadth of the South Korean peninsula regardless of geographical location [4].
As the social burden for people with Parkinson’s disease (PwP) increases, the need for equitable, sustainable, and costeffective health care has been highlighted, with an emphasis on the development of nonpharmacological interventions [5]. In particular, exercise, both aerobic and anaerobic, is an essential adjunctive therapy for PD patients, with recent evidence showing benefits in the gait, balance, mobility, mood, and quality of life (QoL) domains that satisfy unmet needs [6,7]. Furthermore, maintaining physical activity is a protective factor against mortality in patients with PD, which can be achieved by participating in routine exercise [8,9].
The recent COVID-19 pandemic has had a deep impact on the activity levels of PwP; a low level of exercise is related to a subjective increase in motor and nonmotor symptoms [10]. In the hope of providing inclusive and consistent health care beyond geographical boundaries, home-based exercise programs have gained much attention as a means of compensating for reduced opportunities for exercise for PwP [11,12]. Although home-based exercise is proposed to be a strong noninferior alternative to inperson exercise [13], common pitfalls of these exercises include amotivation, attrition, and exercise-related adverse outcomes (e.g., falls, fractures, and musculoskeletal pain), aspects that limit long-term uptake and tolerability [14].
Therefore, this study aimed to address these challenges primarily by evaluating the effect, feasibility, and safety of regularly implemented, live-streaming, group-based, mainly anaerobic tele-exercise sessions provided in a remotely supervised setting on the motor and nonmotor outcomes of a motivated group of PwP. We also explored the demographic and clinical factors associated with the primary outcomes.
Study design and participants
We conducted a 12-week single-center, single-arm, prospective interventional pilot study of PwP who visited a movement disorders clinic at Samsung Medical Center from October 1, 2022 to January 6, 2023. A movement disorder specialist confirmed the diagnosis of idiopathic PD according to the UK Parkinson’s Disease Society Brain Bank diagnostic criteria [15]. Eligible participants who met the following criteria were enrolled consecutively on a first-come, first-served basis: 1) were aged 40–90 years; 2) had Hoehn and Yahr (H&Y) stages I–III; 3) had a stable disease course with no changes in dopaminergic pharmacotherapy for 1 month; and 4) possessed smartphones or equivalent devices and could participate in programs provided through Zoom independently or with the help of a dedicated primary caregiver. The following participants were excluded from the study: 1) patients who were diagnosed with atypical parkinsonism; 2) fall-prone patients who had lost the ability to walk independently; 3) patients with musculoskeletal problems significant enough to hinder participation in exercise; and 4) patients who had significant difficulty accessing the tele-exercise program over Zoom. We aimed to recruit at least 50 patients to reach a power of 0.8 and an alpha error probability of 0.05, adjusting for a potential dropout rate of 20% (Figure 1).
The Institutional Review Board of Samsung Medical Center approved this study (identifier: 2022-07-079). Written informed consent was obtained from all participants and all data were anonymized. All methods were carried out according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines and were extended to non-pharmacological interventions.
Exercise program
The exercise program consisted mainly of stretching, resistance band exercises, and core muscle-building exercises aimed at improving posture and overall flexibility and relieving musculoskeletal pain arising from limited motion, which is frequently problematic for PwP. The target muscles included the iliopsoas, gluteal, deep pelvic, hamstring, lumbar, scapular, and cervical muscles. The full syllabus for our program can be found in Supplementary Table 1 (in the online-only Data Supplement). Each Zoom session lasted 40 min and consisted of a balanced proportion of stretching and strengthening exercises. Patients were allowed to interact actively through a microphone and chat box during the exercise session, and turning on the camera was mandatory to ensure the patients’ safety and participation. The exercise intensity was set to a uniform mild-to-moderate degree to allow for maximum participation. The program was carried out over Zoom by one registered nurse and one sports rehabilitation expert, who were both licensed yoga and pilates instructors specializing in rehabilitative exercises for patients with movement disorders (K.H.Y. and Y.N.Y.), and a movement disorder specialist (J.W.C.). Each session focused on a different subset of target muscles, allowing the patients to be exposed to a new set of exercises for each consecutive session.
Data collection

Demographic data

Demographic data, including sex, age, height, weight, body mass index, years of education, and duration of the disease, were collected at baseline.

Outcome measures

The following motor and nonmotor clinical scales were used by a movement disorder specialist at baseline and after 12 weeks to evaluate the effectiveness of the exercise intervention: the modified H&Y stage [16], Unified Parkinson’s Disease Rating Scale (UPDRS) Parts I–IV [17], Hospital Anxiety and Depression Scale (HADS; 14 items) [18], Nonmotor Symptom Scale (NMSS; 30 items) [19], Parkinson’s Disease Questionnaire (PDQ-39; 39 items) [20], Parkinson’s Disease Sleep Scale (PDSS; 15 items) [21], Parkinson’s Disease Fatigue Scale (PFS-16; 16 items) [22,23], Scales for Outcomes in Parkinson’s Disease-Autonomic (SCOPA-AUT; 25 items) [24], and Montreal Cognitive Assessment test [25]. The baseline assessments were performed within a maximum of 1 month before the start of the exercise program and within a maximum of 1 month following the termination of the study. Importantly, the motor assessments were performed in the best “on” state, as patients were advised to train at “on” periods to maximize the benefits of the exercise and avoid potential complications [12]. Attendance was taken at the end of each session. The overall attendance rate (%) per patient was calculated as the percentage of sessions in which the patient participated over the 24 sessions.
An 11-part postintervention exit survey was administered to all participants within 1 month following the termination of the program to evaluate the feasibility, satisfaction, accessibility, and appropriateness (both intensity and frequency of exercise sessions) of the intervention, the subjective changes reported by the patients, their reasons for not being able to participate, and whether they would participate again if given the opportunity.
Safety and adverse event monitoring
All participants remained on the same drug regimen for 12 weeks after undergoing a meticulous examination at baseline; however, to ensure safety, patients who needed to make changes to their medication were allowed to do so and were excluded from the study. Additionally, we distributed fall prevention pamphlets containing scenarios in which the participants could fall and practical strategies to cope with the risk of falling. Adverse events were routinely monitored by a movement disorder specialist during each consecutive Zoom session, and special attention was given to patients who reported falls or had concerns about falling during the exercise session. Furthermore, patients were encouraged to freely discuss any notable pain or dizziness that may have worsened during the exercise sessions.
Statistical analyses
Descriptive statistics were determined based on the data attributes. Continuous data are presented as the mean ± standard deviation, and categorical data are presented as absolute and relative frequencies—number (%). Changes in clinical scale scores are expressed as “Δ (name of the scale)” (e.g., ΔHADS-A) and were calculated as follows: (postexercise scale score – preexercise scale score)/preexercise scale score (%).
For the primary outcome, the absolute differences in the mean scores on the nonmotor and motor clinical scales before and after the 12-week tele-exercise intervention were analyzed using paired t-tests. Supplementary analyses were performed as follows: 1) a comparison of postexercise improvement between participants with high attendance (≥ 50%) and low attendance (< 50%); and 2) an intragroup pairwise comparison for participants with high attendance (≥ 50%).
For the secondary outcome, we used Pearson correlation analysis to identify whether any notable demographic or clinical characteristics at baseline were associated with changes in clinical outcomes postintervention or with overall compliance with the program. The correlation between the motor and nonmotor clinical scale scores was also evaluated. The correlation analysis was performed only for variables that showed statistically significant differences before and after exercise in the primary outcome analysis.
Statistical analyses were performed using IBM SPSS Statistics (version 24.0; IBM, Armonk, NY, USA) and Rex software (version 3.6.0; RexSoft Inc., Seoul, Korea). Boxplots, correlation matrices, and scatter plots were drawn using R statistical software (version 4.1.2; R Foundation for Statistical Computing, Vienna, Austria).
Trial registration
This study was registered in the Clinical Research Information Service registry under KCT0007810 (registered on November 6, 2022).
Baseline characteristics
A total of 57 PwP were initially screened for eligibility, but one declined to participate in the study. There were no exclusions due to other criteria, including medication changes. Ultimately, 56 participants were enrolled in this study. Two patients dropped out from the program early, leaving 54 participants for the analysis (Figure 1). The mean age was 65.8 years. The mean duration of the disease was 5.4 years, and the mean H&Y stage was 1.9.
Comparison of motor and nonmotor symptoms pre- and postintervention
For the nonmotor clinical scales, the HADS-anxiety (HADSA) and HADS-depression (HADS-D) scores decreased significantly following the 12-week tele-exercise program (4.2 ± 4.1 vs. 2.9 ± 3.2, p = 0.007; 4.9 ± 4.1 vs. 3.4 ± 3.5, p < 0.001, respectively). Furthermore, PFS-16 scores were significantly lower after the tele-exercise intervention (37.3 ± 15.9 vs. 33.7 ± 14.4, p = 0.026). In particular, scores on the SCOPA-AUT urinary symptom subscale were greater following the exercise intervention (4.7 ± 3.9 vs. 5.6 ± 5.0, p = 0.014).
For the motor scales, the UPDRS Part III score, UPDRS total score, and H&Y stage significantly improved after the 12-week tele-exercise program (15.7 ± 6.0 vs. 12.3 ± 6.4, p < 0.001; 25.7 ± 12.9 vs. 22.7 ± 11.8, p = 0.015; and 1.9 ± 0.7 vs. 1.7 ± 0.6, p = 0.027, respectively). Further analysis of the UPDRS Part III subscales revealed significant improvements in axial symptoms, rigidity, and bradykinesia but not in tremor (Figure 2 and Supplementary Table 2 in the online-only Data Supplement).
When we compared participants with high attendance (≥ 50%) with participants with low attendance (< 50%), we found greater improvement in the UPDRS total score in the high-attendance group than in the low-attendance group (-16.6 ± 36.2 vs. 21.0 ± 88.8, p = 0.038) (Supplementary Table 3 in the online-only Data Supplement). Furthermore, when only patients with a participation rate ≥ 50% were included (n = 34), significant improvements were still found in the HADS-A score, HADS-D score, UPDRS Part III score, UPDRS total score, and H&Y stage (Supplementary Table 4 in the online-only Data Supplement).
Patient-specific factors associated with clinical outcomes

Correlations between baseline patient factors and clinical outcomes

The ΔHADS-A score showed a moderate correlation with the baseline HADS-A score (r = -0.330, p = 0.037). The ΔHADS-D score showed a moderate association with the baseline H&Y stage (r = -0.313, p = 0.044). The ΔUPDRS Part III score showed a mild-to-moderate association with the baseline UPDRS Part III score and H&Y stage (r = -0.279, p = 0.046 and r = -0.349, p = 0.014, respectively). The ΔUPDRS total score showed a mild association with the baseline UPDRS total score (r = -0.288, p = 0.040), and finally, the ΔPFS-16 score showed a broad mild-tomoderate association with the baseline HADS-A score, HADSD score, PDQ-39 total score, NMSS urinary domain score, and NMSS total score (Figure 3 and Supplementary Table 5 in the online-only Data Supplement).

Correlations between motor and nonmotor clinical outcomes

The ΔHADS-A score showed a strong positive association with the ΔHADS-D score, ΔH&Y stage, and ΔPFS-16 score (r = 0.779, p < 0.001; r = 0.595, p < 0.001; and r = 0.725, p < 0.001, respectively). ΔHADS-D scores showed moderate to strong positive associations with ΔH&Y stage, ΔPFS-16 score, and ΔUPDRS Part III score (r = 0.845, p < 0.001; r = 0.575, p < 0.001; and r = 0.322, p = 0.038; respectively). The ΔPFS-16 score showed a moderate positive association with the ΔH&Y stage (r = 0.376, p < 0.05). The correlation matrix between changes in motor and nonmotor outcomes postintervention is summarized in Figure 3 and Supplementary Table 5 (in the online-only Data Supplement).
Exploratory analysis: patient-specific factors associated with compliance
Compliance, equated to the overall attendance rate in our study, showed a moderately negative association with the scores on the NMSS subscales for cardiovascular events, including falls. Moreover, the overall attendance rate showed a moderate positive association with the baseline H&Y stage, a mild positive association with the baseline UPDRS Part III score, and a mild positive association with the improvement in the UPDRS total score (Supplementary Figure 1 in the onlineonly Data Supplement).
Feasibility and safety outcomes
No notable adverse events, including falls or worsened musculoskeletal pain directly related to exercise, were reported by any participant.
In the postintervention survey, 46 (85.2%) participants were satisfied with the program, 45 (83.4%) stated that they were able to participate in more than half of the exercise routines, 51 (94.4%) and 49 (90.8%) responded that the length and frequency of the exercise sessions were appropriate, respectively, 39 (72.2%) experienced subjective improvement following the exercise intervention, and 48 (88.9%) responded that they would like to participate in tele-exercise sessions if given a chance. Eleven (20.4%) participants felt that accessing the tele-exercise session via Zoom was difficult.
All participants participated at least once during the livestreaming tele-exercise sessions. Ten participants participated in < 10% of the sessions; these participants attended one or two of the first two sessions and stopped attending afterward. The mean overall attendance rate was 60.0% (Table 1).
Of the 11 patients who responded to question regarding the reasons why they were unable to participate, six had overlapping personal schedules, two had lumbar and leg pain that had manifested before the exercise session, one felt anxiety about turning on the camera, and two experienced technical difficulties.
This 12-week single-arm interventional pilot trial included 56 PwP and revealed the motor and nonmotor benefits of a live-streaming, anaerobic tele-exercise program. We used this scheme to maximize the benefits of home-based training and the motivational effects of group exercises and comradery. The program was safe and feasible, with an attrition rate of 3.6% and overall adherence rate of 60%. We found that the participants experienced improvements in motor function, mood, and fatigue after completing the 12-week exercise program. It is crucial to note that there were, if any, improvements in this study, as PD is a neurodegenerative disease. Having more severe symptoms at baseline was associated with experiencing greater improvement. Adherence to the tele-exercise intervention was positively associated with overall improvements in the total UPDRS score. Improvements in motor symptoms were closely related to improvements in nonmotor symptoms. Finally, patients who experienced dizziness at baseline were less likely to attend sessions.
Importantly, the setup used in our study addresses two main concerns in telehealth exercise interventions: motivation and safety. Motivation was achieved by using an interactive group workout setting to boost comradery and communication among the patients, caregivers, and health care workers involved in the exercise session, incorporating core qualities exclusive to in-person center-based exercises. Furthermore, extra care was taken to maintain safety during and after the exercise sessions to avoid patient harm related to the exercise. In doing so, we prevented adverse events and maintained a positive tone throughout the study, prolonging the motivation cycle of the participants. Compared to conventional exercise paradigms, our tele-exercise program provided easy access to quality exercise in a familiar and safe environment. Moreover, the participants could participate in the exercise session according to their own individual capacities without the conscious burden of trying to keep up with other participants. To enhance safety, supervision by three individuals, both on-site by the caregiver and remotely by two medical personnel (the lecturer and a silent overseer), was used. Cameras were used to view the patient’s whole body and the surrounding environment to assess potential fall risks. For compliance, we recommend an interactive session that involves motivating the patient to speak up by using the chat box function or the mic during or immediately after the exercise session.
Our results are in line with the benefits shown in previous home-based or tele-exercise studies using anxiety, depression, and UPDRS Part III scores as outcomes [12,26-29]. One randomized controlled trial using mixed aerobic and anaerobic exercise, in parallel with our findings, comprehensively showed improvements in anxiety, depression, fatigue, and motor symptom scores [30]. However, in our study, QoL did not improve following the exercise intervention, unlike several studies that reported significant improvements [26,29,30].
Although the benefits of aerobic exercise have been reported in multiple studies linked to mechanisms such as enhanced functional connectivity [31], neural plasticity [32], and dopaminergic signaling [33], only a few studies have evaluated the effects of anaerobic exercise. However, we believe that anaerobic exercises are of paramount importance in maintaining posture and offsetting axial symptoms by strengthening core muscles and addressing range-of-motion limitations through stretching for PwP. At the molecular level, evidence of the reduction in oxidative stress has been suggested as an underlying mechanism [34]. Furthermore, in our study, we did not strictly limit the total amount of exercise outside of our exercise program. We do not believe that our exercise routine alone influenced the clinical improvement observed in our results; rather, we may have improved the general functionality of the body, which could lead to better ambulatory activity and further clinical improvements. Notably, urinary symptoms, denoted by the urinary domain of the SCOPA-AUT, increased after the intervention. The urinary domain consists of six questions on incontinence, retention, and urinary frequency. When the scale was broken down into single questions, a statistically significant difference was found only for the question about urinary frequency (p = 0.030). We hypothesized that due to the strain of the core muscles following our exercise program, patients were more likely to experience increased intraperitoneal pressure and subsequent external stimulation of the bladder. However, within the limitations of our study, this interpretation is largely speculative, and we cannot rule out disease progression as an alternative explanation.
Improvements in nonmotor and motor symptoms showed a strong positive correlation in our study, suggesting a synergistic effect. Our results may help elucidate the interplay between nonmotor and motor functional connectivity in PwP, indicating that exercise programs should not only target certain aspects of PD symptoms but also address different aspects simultaneously to achieve maximal effects. Interestingly, the improvements in fatigue in our study were correlated with greater mood, autonomic, and motor impairments at baseline and improvements in mood symptoms and H&Y stage. Fatigue is a composite entity that is universally associated with nonmotor and motor features [35]. Therefore, this association supports our hypothesis that motor and nonmotor symptoms improve synergistically following exercise interventions.
Our analysis of compliance suggested that patients with greater motor disabilities may have higher adherence rates, which, in turn, may be associated with better motor and nonmotor outcomes. This demonstrates that if given the right opportunity, these patients can achieve an improved health status. One factor that hindered attendance was orthostatic dizziness, which is represented by the first domain of the NMSS. To achieve optimal results for patients, screening for these findings before starting the exercise session should be performed to make the patient feel more comfortable performing the exercises. This can also prevent adverse events such as syncope associated with orthostatic hypotension.
Our study had several notable limitations. First, this study included a small group of patients without a control group. Future studies should use control groups that are matched for age, sex, and disease duration. We are currently conducting a multicenter randomized clinical study to validate our results. Second, most participants were motivated patients who were willing to participate in the study and were well aware that their scores would be followed up after the exercise, leading to selection bias and the Hawthorne effect. Third, we did not use UPDRS scores to track motor improvement in the “off” state. However, our original hypothesis focused on maximal improvement in the “on” state, which was measured in our study as a marker of motor improvement. Fourth, we tested only the anaerobic mode of exercise, limiting the generalizability of our study. Although this decision was influenced by safety concerns, the relative paucity of evidence on anaerobic tele-exercise and posture-specific benefits that can facilitate other modes of exercise, relieve pain, and possibly prevent falls may justify the conclusions we drew from this pilot study. Finally, we did not collect data on the total amount of daily exercise per patient outside of our program, which may have influenced the results.
Conclusions
There are still limitations to pharmacological treatment and surgical options for PD. Current medical therapies can partially alleviate symptoms but only at the cost of dose-limiting side effects. Moreover, the therapeutic window narrows with disease progression, leaving patients with increasing disability. Surgical therapies such as deep brain stimulation are not available in all centers, are expensive, and have strict guidelines that limit their use. Therefore, we believe that there are still some unfilled gaps in nonpharmacological interventions, such as exercise interventions, that can be of substantial benefit. If performed safely in a feasible amount, group-based regular anaerobic exercise in a semisupervised tele-exercise setting can effectively provide equitable adjunctive health care benefits to PwP. Furthermore, patients who are anxious, fatigued, and have greater motor disabilities may be the best responders to the program.
The online-only Data Supplement is available with this article at https://doi.org/10.14802/jmd.23251.
Supplementary Table 1.
Weekly schedules of tele-exercise in PD
jmd-23251-Supplementary-Table-1.pdf
Supplementary Table 2.
Comparison of clinical scales before and after live-streaming tele-exercise intervention in full format
jmd-23251-Supplementary-Table-2.pdf
Supplementary Table 3.
Comparison of clinical outcomes between low-attendance vs. high-attendance participants
jmd-23251-Supplementary-Table-3.pdf
Supplementary Table 4.
Paired-T statistics for patients with attendance ≥ 50%
jmd-23251-Supplementary-Table-4.pdf
Supplementary Table 5.
Correlation matrix between delta-clinical scales and relevant baseline scales in full format
jmd-23251-Supplementary-Table-5.pdf
Supplementary Figure 1.
Scatterplot showing a correlation between compliance level (overall attendance) and relevant clinical scales at baseline. A: H&Y stage. B: NMSS first domain. C: UDPRS Part III. D: ΔUDPRS Part III. E: UPDRS total score. F: ΔUDPRS total score. Lower negative delta-clinical scales mean more improvement. H&Y, Hoehn and Yahr; NMSS_1_T, Non-Motor Symptom Scale, 1st domain; UPDRS, Unified Parkinson’s Disease Rating Scale.
jmd-23251-Supplementary-Fig-1.pdf

Conflicts of Interest

The authors have no financial conflicts of interest.

Funding Statement

This research was supported by a fund (2022-ER1005-01) by the Korea Disease Control and Prevention Agency.

Author Contributions

Conceptualization: Jin Whan Cho, Jong Hyeon Ahn, Jinyoung Youn. Data curation: Jong Hyeon Ahn, Jiwon Yoo, Ji One Song, Hye Young Kim. Formal analysis: Jongmok Ha, Jung Hyun Park. Funding acquisition: Jin Whan Cho, Jong Hyeon Ahn. Investigation: Jin Whan Cho, Hye Young Kim, Jong Hyeon Ahn, Jiwon Yoo, Ji One Song. Methodology: Jin Whan Cho, Jinyoung Youn, Jong Hyeon Ahn. Project administration: Jin Whan Cho, Jong Hyeon Ahn. Resources: Jin Whan Cho, Jong Hyeon Ahn. Software: Jongmok Ha. Supervision: Jin Whan Cho, Jong Hyeon Ahn, Jun Seok Lee. Validation: Jong Hyeon Ahn, Jun Seok Lee. Visualization: Jongmok Ha. Writing—original draft: Jongmok Ha, Jung Hyun Park. Writing—review & editing: Jin Whan Cho.

The authors acknowledge the support of the patients and their caregivers who participated in this study for their daily inspiration. Their relentless efforts to fight the disease motivated us and drove us as researchers. We also extend our thanks to K.H.Y. and Y.N.Y. for making significant efforts during the study period to seamlessly provide participants with quality exercise routines.
Figure 1.
Study flow at-a-glance. A: Flow diagram. B: Assessment protocol. HADS-A, Hospital Anxiety and Depression Scale-anxiety; HADSD, Hospital Anxiety and Depression Scale-depression; PFS-16, Parkinson’s Disease Fatigue Scale; NMSS, Nonmotor Symptom Scale; PDSS, Parkinson’s Disease Sleep Scale; PDQ-39, Parkinson’s Disease Questionnaire; SCOPA-AUT, Scales for Outcomes in Parkinson’s Disease-Autonomic; MoCA, Montreal Cognitive Assessment; UPDRS, Unified Parkinson’s Disease Rating Scale; H&Y, Hoehn and Yahr.
jmd-23251f1.jpg
Figure 2.
Comparison of clinical scale scores before and after the live-streaming tele-exercise intervention. The boxplots show the medians (interquartile ranges). The red crossbar represents the mean value. The boxplots in blue represent the preexercise intervention scores, and the red boxplots represent the postintervention scores. The significance level is based on the analysis using the mean value. A: HADS-anxiety. B: HADS-depression. C: PFS-16. D: UPDRS Part III. E: UPDRS total score. F: H&Y stage. *p < 0.05; **p < 0.01; ***p < 0.001. HADS, Hospital Anxiety and Depression Scale; PFS-16, Parkinson’s Disease Fatigue Scale; UPDRS, Unified Parkinson’s Disease Rating Scale; H&Y, Hoehn and Yahr.
jmd-23251f2.jpg
Figure 3.
Correlation matrix of relevant clinical scale scores at baseline and delta clinical scale scores. Lower negative delta clinical scale scores indicate greater improvement. *p < 0.05; **p < 0.01; ***p < 0.001. HY, Hoehn and Yahr; UPDRS; Unified Parkinson’s Disease Rating Scale; HADS_D, Hospital Anxiety and Depression Scale-depression; HADS_A, Hospital Anxiety and Depression Scale-anxiety; PFS16, Parkinson’s Disease Fatigue Scale; NMSS, Nonmotor Symptom Scale; PDQ39, Parkinson’s Disease Questionnaire.
jmd-23251f3.jpg
Table 1.
Demographics summary of participants (pre-intervention baseline) and overall compliance
Variables Value (n = 56)
Sex
 Male 20 (35.7)
 Female 34 (64.3)
Age (yr) 65.8 ± 7.5
Disease duration (yr) 5.4 ± 4.3
Education (yr) 13.2 ± 3.5
Body mass index (kg/m2) 23.9 ± 3.2
Attendance (%) 60.0 ± 36.0
Clinical scales
 HADS-A 4.4 ± 4.4
 HADS-D 5.1 ± 4.2
 PDQ-39 total 13.8 ± 13.5
 NMSS total 22.1 ± 20.4
 PDSS total 122.9 ± 18.8
 PFS-16 total 38.1 ± 16.4
 SCOPA-AUT total 16.2 ± 8.8
 UPDRS III total 15.6 ± 5.9
 H&Y stage 1.9 ± 0.6
 K-MoCA 26.7 ± 3.4

Values are presented as mean ± standard deviation or n (%).

HADS-A, Hospital Anxiety and Depression Scale-anxiety; HADS-D, Hospital Anxiety and Depression Scale-depression; PDQ-39, Parkinson’s Disease Questionnaire; NMSS, Nonmotor Symptom Scale; PDSS, Parkinson’s Disease Sleep Scale; PFS-16, Parkinson’s Disease Fatigue Scale; SCOPA-AUT, Scales for Outcomes in Parkinson’s Disease-Autonomic; UPDRS, Unified Parkinson’s Disease Rating Scale; H&Y, Hoehn and Yahr; K-MoCA, Korean version of Montreal Cognitive Assessment.

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