BJMB
Brazilian Journal of Motor Behavior
Special Issue:
COVID-19 (coronavirus disease): Impacts on motor behavior
!
Santinelli et al.
2021
VOL.15
N.1
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Synchronous and asynchronous remote exercise may improve motor and non-motor
symptoms in people with Parkinson’s disease during the COVID-19 pandemic
FELIPE B. SANTINELLI
1
| LUCAS SIMIELI
1
| ELISA DE C. COSTA
1
| LETICIA N. MARTELI
1,2
| CHIEN H. FEN
3,4
| ERICA
TARDELLI
3
| ERIKA OKAMOTO
3
| KATIA TANAKA
3
| FABIO A. BARBIERI
1
1
São Paulo State University (UNESP), School of Sciences, Graduate Program in Movement Sciences, Department of Physical Education, Human Movement Research
Laboratory (MOVI-LAB), Bauru, SP, Brazil.
2
São Paulo State University (UNESP), School of Architecture, Arts and Communication (FAAC), Postgraduate Program in Design, Ergonomic and Interfaces Laboratory
(LEI), Bauru, SP, Brazil. University of Lisbon (ULisboa), School of Architecture (FA), Doctoral Program in Design, Research Centre for Architecture, Urbanism and Design
(CIAUD), Lisbon, Portugal.
3
Associação Brasil Parkinson (ABP), São Paulo, SP, Brazil.
4
Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brazil.
Correspondence to:!Fabio Augusto Barbieri. Av. Eng. Luiz Edmundo Carrijo Coube, 14-01, Vargem Limpa. Bauru, SP CEP 17033-360. Phone + 55 14 3103-9612
email: fabio.barbieri@unesp.br
https://doi.org/10.20338/bjmb.v15i1.236
HIGHLIGHTS
• Perform synchronous exercise class resulted
in higher amount of physical activity.
• Synchronous exercise mitigate the anxiety
symptom.
• Asynchronous exercise presented lower
depression symptom than no-exercise group.
• People with PD should be encouraged to
perform synchronous exercise during
pandemic.
ABBREVIATIONS
ABP Associação Brasileira de
Parkinson
FOG Freezing of gait
HAD Hospital Anxiety and Depression
IPAQ International Physical Activity
Questionnaire
MET Metabolic Equivalent of Task
MSQ Mini Sleep Questionnaire
PD Parkinson’s Disease
PDQ-8 Parkinson’s Disease
Questionnaire-8
PDQ-39 Parkinson’s Disease
Questionnaire-39
SARS-Cov-2 Severe acute respiratory
syndrome
PUBLICATION DATA
Received 04 01 2021
Accepted 27 02 2021
Published 01 03 2021
BACKGROUND: Stay active is a good strategy to mitigate the negative effects of confinement in people with
Parkinson’s Disease (PD). Synchronous (full-time class interaction) and asynchronous (without the live presence
of the healthcare professional) exercises are two strategies to avoid the worsening of PD.
AIM: To investigate the effect of the synchronous and asynchronous exercises on motor and non-motor
symptoms, physical activity level, anxiety, depression, sleep quality, and quality of life in people with PD during
the pandemic lockdown.
METHOD: Fifty-eight people with PD responded to an online survey and were divided into synchronous (n=24),
asynchronous (n=19), and no-exercise (n=15) groups. The participants responded to questions regarding motor
and non-motor symptoms, besides the questionnaire of quality of life, physical activity, anxiety and depression,
and sleep quality.
RESULTS: Synchronous group presents higher amounts of physical activity than the asynchronous and no-
exercise groups. Also, the synchronous group presented lower anxiety symptoms, while the asynchronous
group presented lower depression symptoms compared with the no-exercise group. Worse motor symptoms
were presented by the three groups.
CONCLUSION: Stay active during the pandemic lockdown, is beneficial to reduce anxiety and depression
symptoms in people with PD. This population should be encouraged to perform synchronous classes to perform
greater amounts of physical activity, which in the long-term could produce greater benefits.
KEYWORDS: Motor control | Parkinson’s disease | COVID-19 | Exercise | Depression | Motor symptoms
INTRODUCTION
The severe acute respiratory syndrome - SARS-Cov-2 (COVID-19), which caused
a worldwide pandemic, altered the habits of people. Millions of people were infected with
COVID-19, resulting in millions of deaths. Specifically in Brazil, more than 13 million were
infected and more than 330 thousand died (data from April 05,
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https://www.worldometers.info/coronavirus/country/brazil/). To control the rate of
transmission and avoid healthy system breakdown, local governments, including the
Brazilian government, declared full/partial lockdowns or restricted people circulation,
allowing only essential activities. These restrictions increase the time spending at home
working, watching TV, or only sitting, and one consequence was the reduction of the
amount of exercise.
1,2
This reduction of time expending doing exercise results in an
increase in mortality during pandemic lockdown.
3
Thereby, an exercise routine may be a
good strategy to prevent neurological
2
and cardiovascular
4
disease progression and
should be encouraged during home confinement.
Regular practices of physical activity delay Parkinson’s disease (PD) progression.
5
It is well-established that higher levels of physical activity improve PD-related symptoms.
6
On the other hand, lower level of physical activity increases motor (e.g., rigidity, tremor,
akinesia, bradykinesia, unbalance, freezing of gait) and non-motor (e.g., depression,
anxiety, sleep disturbance, fatigue) symptoms.
7
Thus, keeping physically active can be a
good strategy to avoid the negative effects of routine changes due to the COVID-19
pandemic in people with PD. Social distancing and home confinement hindered access to
healthcare professionals, requiring alternative strategies such as home-based remotely
exercise. A bunch of groups have promoted live (synchronous class) or recorded exercise
(asynchronous class) classes during pandemic lockdown to promote exercise among the
population, including people with PD. The synchronous class has full-time interaction
between the healthcare professional and the individual, with controlled intensity prescribed
and with real-time feedback and patient's movement correction.
8,9
Although the
asynchronous class allows the participant to perform the activity at any time of the day, it is
limited or not present any kind of interaction with the class professor during the
performance of class.
9,10
This limited interaction with the patients could influence in some
of training parameters such as the effort of the session. For instance, in longitudinal terms
asynchronous exercise present lower training load values than synchronous exercise,
11
which could affect some workload outcomes-dependents.
Considering that i) pandemic COVID-19 increased the time at home without
exercise, ii) the lack of exercise worse motor and non-motor symptoms in people with PD,
and iii) remotely strategies are the unique safe exercise to avoid COVID-19 infection, we
investigated as synchronous and asynchronous remotely exercise during pandemic
COVID-19 affected the motor and non-motor symptoms, physical activity level, anxiety,
depression, sleep quality, and quality of life during home confinement in people with PD in
the first three months of COVID-19 pandemic (March to June of 2020). We expected that
both groups that performing remotely exercise present lower motor and non-motor
symptoms than the no-exercise group. Besides, the group performing synchronous
exercise would present lower manifestations of motor and non-motor symptoms and a
higher amount of physical activity performed than the asynchronous exercise group. For
the last, we expected that higher levels of physical activity, independent of the group, will
be related with lower PD-related symptoms.
METHODS
Participants
Individuals with PD were invited by social media (Facebook
®
, Instagram
®
), e-mail,
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and WhatsApp
®
to fill an electronic survey (Google
®
Forms). One hundred seven people
with PD responded to this survey. The following inclusion criteria were applied: (i)
diagnosis of PD confirmed by contact with the patient (e.g., social media) or the institution
that they are involved in (e.g., ATIVA PARKINSON, Associação Brasileira de Parkinson -
ABP); (ii) over 35 years old. The exclusion criteria were inadequate questionnaire answers
(e.g., no answered questions) and not answer the type of exercise was performed
(synchronous exercise, asynchronous exercise, or no exercise). The research was
approved by University's local Ethical Committee and all individuals consented to
participate in the study (#32134620.0.0000.5398).
After the inclusion and exclusion criteria check, 58 people with PD were included in
the study. The individuals were distributed into three groups according to exercise type: i)
synchronous exercise group: individuals with PD who performed a live exercise for at least
for two months; ii) asynchronous exercise group: individuals with PD that was performing a
recorded exercise for at least two months; iii) no-exercise group: individuals with PD that
no performed exercise in the two last months.
Study protocol
This is an exploratory and descriptive study. An electronic survey produced in
Google
®
forms was filled by the participants of the study during June of 2020. The survey
has six sections about 1) general information: demographic (e.g., height, weight, and
severity of the PD) and general COVID-19 information (e.g. perception, diagnostic of
COVID-19 and time in lockdown- only allowed essential services); 2) impact on motor and
non-motor symptoms: questions about the effects of home confinement on PD motor
(motor worse, presence of tremor, freezing of gait, unbalance, bradykinesia, and
experience with falls) and non-motor (loneliness, forgetfulness, fatigue and if sleep quality
have been changed) symptoms; 3) quality of life: Parkinson’s Disease Questionnaire-8
(PDQ-8);
12
4) level of physical activity: a short version of International Physical Activity
Questionnaire (IPAQ- short version);
13
5) anxiety and depression: Hospital Anxiety and
Depression (HAD);
14,15
6) quality of sleep: Mini Sleep Questionnaire (MSQ).
16
The
participants answered the questionary from June 15
th
to June 30
th
of 2020.
Quality of life, level of physical activity, anxiety, depression, and quality of sleep
assessments
Several questionnaires were used to the quality of life, level of physical activity,
anxiety, depression, and quality of sleep evaluation. Firstly, the PDQ-8, a shortened
version of the Parkinson’s Disease Questionnaire-39 (PDQ-39), a scale that assesses the
quality of life of these individuals, was answered by the participants. The total score ranges
from 0 to 100, where 0 = no problem and 100 = maximum problem level.
12
Secondly, the
amount of physical activity performed during the lockdown was obtained through the
IPAQ,
13
which is reported here as Metabolic Equivalent of Task (MET). Thirdly, to evaluate
the anxiety and depression aspects the HAD questionnaire was applied, being a score
between 8 and 10 interpreted as possible cases of anxiety and depression and a score
equal or greater than 11, indicates the likely presence of anxiety and depression, more
significantly.
14,15
Fourthly, and finally, the sleep quality was measure with the MSQ. The
total score is divided into levels of difficulty sleeping being: good sleep quality (10 to 24
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points); mild difficulty (25 to 27 points); moderate difficulty (28 to 30 points); severe
difficulty sleeping (31 points or more).
16–18
Data and statistical analysis
The demographic characteristics, and self-reported motor and non-motor
symptoms were reported in Table 1, 2, and 3, respectively. The demographic
characteristics were expressed in the average of the absolute values, while self-reported
motor and non-motor symptoms were presented as a percentage. The level of physical
activity (IPAQ), quality of life (PDQ-8), quality of sleep (MSQ), anxiety, and depression
(HAD) were compared among groups using univariate analysis (synchronous exercise vs
asynchronous exercise vs no-exercise). Tukey post hoc, with significant levels adjusted,
was used when ANOVA showed a significant effect. We also performed a correlation
analysis, through Spearman rank correlation, between the IPAQ with the PDQ-8, MSQ,
HAD-anxiety, and HAD-depression. Correlation coefficients of 0.1, 0.3, and 0.5 were
interpreted as weak, moderate, and strong, respectively.
19
All analyses were conducted
using SPSS software version 26 (IBM Corporation, Armory, NY) and significance was set
at p<0.05.
RESULTS
Demographic
Table 1 presents the demographic data. Only one subject of the non-exercise
group maybe was positive for COVID-19. The majority of the participants from both groups
maintained the habitual PD medicine, and the asynchronous group was more time in
lockdown (more than 7 weeks- 94.7%) than the synchronous group (79.2%), and non-
exercise group (80%). The majority of the participants from the three groups live with
someone (more than 80%).
Motor symptoms
The answers for motor symptoms are presented in Table 2. The majority of the
participants observed worsening in motor symptoms during the lockdown period
(asynchronous: 63%, synchronous: 79%, and no-exercise: 73% - total: 72.4%). No-
exercise group presented tremor symptoms and imbalance (46.7% in both symptoms)
more often than both asynchronous (26.4% and 36.8%, respectively) and synchronous
(37.5% and 29.2%, respectively) groups, but they had less often (13.3%) freezing of gait
compared to synchronous (33.3%) and asynchronous (26.3%) groups. Finally, falls were
experienced by the three groups, with a higher percentage in the asynchronous (47.4%)
group compared to both no-exercise (33.3%) and synchronous (29.2%) groups.
Non-motor symptoms
Table 3 presents the answers for non-motor symptoms. The synchronous group
feels lesser isolated (50%) compared to asynchronous (26.3%) and no-exercise (33.3%)
groups. Forgetfulness was perceived worse for the asynchronous (31.6%) and
synchronous (37.5%) than the no-exercise (20%) group. Individuals in the no-exercise
group (46.7%) reported lower sleep quality than asynchronous (36.8%) and synchronous
(25%) groups.
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Table 1 – Anthropometric characteristics, disease record, education level and aspects related to the COVID-19 pandemic lockdowns such as time in isolation and seriousness of the pandemic.
ASYNCHRONOUS EXERCISE GROUP
N = 19
SYNCHRONOUS EXERCISE GROUP
N = 24
NO-EXERCISE GROUP
N = 15
Sex
10 females/9 males
11 females/13 males
9 females/ 6 males
Age (year)
69±8
68±9
64±16
Body Mass (kg)
71±22
74±11
68±14
Stature (m)
1.62±0.12
1.65±0.9
1.64±0.10
Disease duration (years)
8±6
8±6
7±9
Have you taken your PD
medicine properly? (%)
YES, same as before: 94.7
No, less than before: 0
No, more than before: 5.3
I don't take PD medication: 0
YES, same as before: 91.7
No, less than before: 4.2
No, more than before: 4.2
I don't take PD medication: 0
YES, same as before: 100
No, less than before: 0
No, more than before: 0
I don't take PD medication: 0
Live alone
No: 84.2
Yes: 15.8
No: 91.7
Yes: 8.3
No: 80.0
Yes: 20.0
Education level (%)
Elementary School
26.4
16.7
20.0
High School
10.5
8.3
66.7
Undergraduate Degree
52.6
58.3
13.3
Graduate School
10.5
16.7
0
Monthly Income (minimum
wage – R$ 1.045,00)
4±3
5±3
1±1
Positive diagnosis for COVID-
19
YES: 0
MAYBE: 0
NO: 19
YES: 0
MAYBE: 0
NO: 24
YES: 0
MAYBE: 1
NO: 14
Time in isolation (%)
None
0
12.4
6.7
1 - 2 weeks
0
0
0
3 - 4 weeks
0
4.2
6.7
5 - 7 weeks
5.3
4.2
6.7
More than 7 weeks
94.7
79.2
80.0
How serious is the COVID-19 pandemic?
Very serious
73.7
70.8
40.0
Serious
21.0
29.2
33.3
More or less serious
5.3
0
13.3
Little serious
0
0
13.3
Not at all serious
0
0
0
They did not answer
0
0
0
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Table 2 – Self-reported motor symptoms during the quarantine for the asynchronous, synchronous, and no-exercise groups.
ASYNCHRONOUS EXERCISE
SYNCHRONOUS
NO-EXERCISE
Did you notice any motor
worsening? (%)
YES: 63.0
NO: 37.0
YES: 79.0
NO: 21.0
YES: 73.0
NO: 27.0
Did you experience tremor at
rest? (%)
NO: 36.8
YES, more often: 26.4
YES, with the same frequency: 36.8
YES, less frequently: 0
They did not answer: 0
NO: 45.8
YES, more often: 37.5
YES, with the same frequency: 16.7
YES, less frequently: 0
They did not answer: 0
NO: 6.7
Yes, more often: 46.7
Yes, with the same frequency: 46.7
Yes, less frequently: 0
They did not answer: 0
You presented freezing of gait?
(%)
NO: 57.9
YES, more often: 26.3
YES, with the same frequency: 10.5
YES, less frequently: 5.3
They did not answer: 0
NO: 41.7
YES, more often: 33.3
YES, with the same frequency: 12.5
YES, less frequently: 4.2
They did not answer: 8.3
NO: 66.7
YES, more often: 13.3
YES, with the same frequency: 20.0
YES, less frequently: 0
They did not answer: 0
You presented imbalance? (%)
NO: 31.6
YES, more often: 36.8
YES, with the same frequency: 31.6
YES, less frequently: 0
They did not answer: 0
NO: 37.5
YES, more often: 29.2
YES, with the same frequency: 33.3
YES, less frequently: 0
They did not answer: 0
NO: 33.3
YES, more often: 46.7
YES, with the same frequency: 20.0
YES, less frequently: 0
They did not answer: 0
Were your movements slower?
(%)
YES: 63.2
NO: 36.8
YES: 58.3
NO: 41.7
YES: 60.0
NO: 40.0
Did you have falls? (%)
YES: 47.4
NO: 52.6
YES: 29.2
NO: 70.8
YES: 33.3
NO: 66.7
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Table 3 – Self-reported non-motor symptoms during the quarantine for the asynchronous, synchronous, and no-exercise groups.
ASYNCHRONOUS EXERCISE
SYNCHRONOUS
NO-EXERCISE
Do you feel isolated (loneliness)? (%)
NO: 26.3
YES, more often: 54.1
YES, with the same frequency: 15.8
YES, less frequently: 3.8
They did not answer: 0
NO: 50
YES, more often: 33.3
YES, with the same frequency: 8.3
YES, less frequently: 2.0
They did not answer: 4.2
NO: 33.3
YES, more often: 66.7
YES, with the same frequency: 0
YES, less frequently: 0
They did not answer: 0
Have you forgotten things (forgetfulness)?
(%)
NO: 21.0
YES, more often: 31.6
YES, with the same frequency: 47.4
YES, less frequently: 0
They did not answer: 0
NO: 29.2
YES, more often: 37.5
YES, with the same frequency: 29.2
YES, less frequently: 4.2
They did not answer: 0
NO: 60.0
YES, more often: 20.0
YES, with the same frequency: 20.0
YES, less frequently: 0
They did not answer: 0
Have you been tired (fatigue)? (%)
NO: 36.8
YES, more often: 31.6
YES, with the same frequency: 31.6
YES, less frequently: 0
They did not answer: 0
NO: 25.0
YES, more often: 45.8
YES, with the same frequency: 25.0
YES, less frequently: 4.2
They did not answer: 0
NO: 40.0
YES, more often: 40.0
YES, with the same frequency: 20.0
YES, less frequently: 0
They did not answer: 0
Has your sleep quality changed? (%)
NO: 52.6
YES, it got worse: 36.8
YES, it improved: 10.5
They did not answer: 0
NO: 58.3
YES, it got worse: 25.0
YES, it improved: 12.5
They did not answer: 4.2
NO: 53.3
YES, it got worse: 46.7
YES, it improved: 0
They did not answer: 0
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Physical activity, depression and anxiety level, quality of sleep, and quality of life
ANOVA indicated significant difference for level of physical activity (F
2,58
=5.73,
p<0.005), anxiety (F
2,58
=3.40, p<0.04) and depression (F
2,58
=3.26, p<0.04) (Figure 1). Post
hoc analysis showed that the synchronous exercise group had a higher physical activity
level than both asynchronous exercise (p<0.05) and no-exercise (p<0.007) groups. Also,
the no-exercise group presented higher anxiety than the synchronous exercise group
(p<0.04) and higher depression levels compared with the asynchronous exercise group
(p<0.05).
Figure 1. Means and standard deviation of level of physical activity (IPAQ), anxiety (HAD), sleep quality
(MSQ), depression (HAD), and quality of life (PDQ-8). * Significant differences between groups.
Correlation’s analysis
Higher levels of physical activity, obtained by the IPAQ, was significant correlated
with lower depression (moderate relationship) and with anxiety (weak relationship)
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symptoms considering the three groups. No significant correlations were observed
between the IPAQ and sleep quality (MSQ) and quality of life (PDQ-8).
Figure 2. Correlations between the physical activity questionnaire (IPAQ), anxiety (HAD-anxiety), sleep quality
(MSQ), depression (HAD-depression), and quality of life (PDQ-8). The curved line represents the 95%
confidence intervals.
DISCUSSION
In the present study, we investigated the impact of synchronous exercise,
asynchronous exercise, and no performance of exercise on the motor and non-motor
symptoms, physical activity level, anxiety, depression, sleep quality, and quality of life in
people with PD during the pandemic lockdown. The main findings of the study were: i) the
three groups presented worsens in symptoms during quarantine of COVID-19 pandemic
lockdown, with the no-exercise group presenting more often worsens in tremor, imbalance
and sleep symptoms, ii) synchronous exercise presented higher amount of physical activity
compared to asynchronous and no-exercise groups, iii) synchronous exercise reduced
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levels of anxiety and asynchronous exercise reduced levels of depression compared to the
no-exercise group, iv) Higher levels of physical activity were associated with lower anxiety
and depression symptoms in people with PD. The results confirmed in part our hypothesis.
Our results suggest that that performing exercise remotely, under or not supervision, is
beneficial for motor and non-motor symptoms in people with PD during pandemic COVID-
19 lockdown, improving the level of physical activity.
Sustain higher amounts of physical activity, mainly during pandemic COVID-19
lockdown, is essential for the maintenance of health in people with PD. In an Italian survey
during the pandemic lockdown, 62.3% of the people with PD reported that they did not
perform any kind (42.3%) or poor (20%) physical activity, while only 37.6% responded that
only home-based physical activity was performed.
1
In another Italian survey, Schirinzi et
al.
2
observed that the patients which perceived worsening during pandemic lockdown
(~60%), performed a lower amount of physical activity (1714±1570 METS) vs those who
not reported worsening of motor symptoms (2399±2412 METS), indicating that the amount
of physical activity performed is the main risk factor associated with the perception of
worsening of motor symptoms. In our study, the amount of physical activity observed was
lower compared with the Schirinzi et al.
2
study, even in the synchronous group
(1057±1142 METS). This explains why most of our cohort reported, in general, worsening
of motor and non-motor symptoms. However, the no-exercise group showed worsen
balance and tremor compared to synchronous and asynchronous exercise groups during
the pandemic lockdown, which could indicate some exercise benefits on those aspect.
Nevertheless, both exercise groups presented more recurrence of freezing of gait (FOG)
symptom than no-exercise group, but maybe for the fact that the exercise groups spending
more time (i.e., greater amount of physical activity) in situations that could produce FOG
(e.g., pass through a door).
The synchronous exercise group presented a significantly lower anxiety score
while the asynchronous exercise group presented a lower depression score than the no-
exercise group. Also, although non-significant, the synchronous group presented a lower
depression score and the asynchronous group presented lower anxiety compared with
those who not performed exercise. It is common for people with PD to report higher levels
of anxiety and depression,
20
which could be exacerbated during pandemic restrictions.
21
Pandemic lockdown could cause stress, anxiety, social isolation, and psychological
distress
22
and be associated with unpleasant emotions, sadness, anger, and frustrations.
4
This worsening in mental health aspects could be related to a reduced amount of physical
activity. Anyan et al.
23
observed that reduced physical activity was associated with a higher
risk to develop anxiety and depressive symptoms during the pandemic. It is well-
established that physical activity is essential to decrease anxiety and depression
symptoms in a range of populations, including PD.
24
Confirming these previous studies, the
correlations of our study showed that maintain higher levels of physical activity during
confinement could ease the anxiety and depression symptoms in people with PD. Thereby,
it seems that perform any kind of exercise class, synchronous or not, seems to be
beneficial to improve mental health during the pandemic lockdown. However, the amount
of physical activity seems to change between the two types of exercise class and with
those who have not participated in either of both classes.
Performing a synchronous or asynchronous class exercise showed similar results
for people with PD for motor and non-motor symptoms, but a greater amount of physical
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activity for the synchronous group was observed compared with the other two groups.
During the pandemic lockdown, Gomes Costa et al.
11
investigated the difference between
synchronous and asynchronous classes in spinal cord injuries patients. Greater benefits
for synchronous classes were observed related to total and weekly average workload and
program adherence over the asynchronous classes. This corroborates with the literature.
Perform exercise under professional supervision provides greater results (e.g., higher
motivation, specific orientation, correction of movement, optimal frequency, intensity, and
volume) when compared with exercise without supervision.
25
. The fact that the
synchronous group in our study presented higher amounts of physical activity may suggest
some of these benefits performing exercise under supervision (e.g., greater adherence and
higher workload). In addition, we suggest that perform synchronous exercise reduced the
feeling of isolation, which indicates that synchronous activities may reduce loneliness
during the lockdown. This may be an important aspect considering the high number of
psychological and cognitive problems reported during pandemic.
4,22
Thus, given that no
social interaction could increase anxiety
26
and depression
27
symptoms the synchronous
exercise, which provide social interaction, seems to be the most recommended to mitigate
these non-motor symptoms. In addition, once the synchronous exercise provides a greater
amount of physical activity than asynchronous exercise and no-exercise, which may reflect
a decrease in motor and non-motor symptoms in a long-term investigation.
Although some important findings were obtained in the present study, some
precautions should be considered to interpret the results. First, we were not able to
evaluate the participants before the pandemic lockdown, which limits our results based
only on an observation. Besides, we can not to match the groups in accord with the sex
which could certainly influence motor and non-motor symptoms in people with PD.
28
We
propose for future studies to address these issues comparing pre and post
synchronous/asynchronous class exercise exposure to confirm, or not, our findings.
Thereby, it will be possible to confirm if the differences observed were indeed due to the
performance of each exercise modality or due the baseline differences among groups.
Second, it is not possible to confirm if the groups were matched for the PD disability level,
influencing the perception of the participants related to motor and non-motor symptoms,
explaining the lack of difference for some parameters among the groups.
29
Third, a
longitudinal study could strength our findings, confirming (or not) the benefits of
synchronous or asynchronous exercise during pandemic COVID-19 lockdown. For the last,
as the present study it is an observational study, we were not able to control the
parameters of the exercise groups such as the type of exercise, intensity, volume,
frequency or duration of each session which could influence the outcomes evaluated.
CONCLUSION
This study demonstrated that stay active, through synchronous or asynchronous
exercises, during COVID-19 pandemic lockdown is beneficial for motor and non-motor
symptoms, especially for anxiety and depression, in people with PD. In addition,
synchronous exercise increased the level of physical activity compared to asynchronous
exercises and no-exercise. Based on our survey, people with PD and their caregivers
should plan for access to a remote exercise class (preference for synchronous class) to
preserve or improve motor and non-motor symptoms. In the absence of the possibility to
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achieve synchronous class, these populations should be encouraged to perform any kind
of physical activity to preserve health and to prevent the worse of PD.
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ACKNOWLEDGEMENTS
The authors would like to thank all the participants to contribute with this research.
Citation: Santinelli FB, Simieli L, Costa EC, Martineli LN, Fen CH, Tardelli E, Okamoto E, Tanaka K, Barbieri FA.
Synchronous and asynchronous remote exercise may improve motor and non-motor symptoms in people with
Parkinson’s disease during the COVID-19 pandemic. BJMB. 2021:15(1): 47-60.
Editors: Dr Fabio Augusto Barbieri - São Paulo State University (UNESP), Bauru, SP, Brazil; Dr José Angelo Barela -
São Paulo State University (UNESP), Rio Claro, SP, Brazil; Dr Natalia Madalena Rinaldi - Federal University of
Espírito Santo (UFES), Vitória, ES, Brazil.
Copyright:© 2021 Santinelli, Simieli, Costa, Martinelli, Fen, Tardelli, Okamoto, Tanaka and Barbieri and BJMB. This is
an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No
Derivatives 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-
profit sectors.
Competing interests: The authors have declared that no competing interests exist.
DOI:$https://doi.org/10.20338/bjmb.v15i1.236