BJMB
Brazilian Journal of Motor Behavior
Special Issue:
COVID-19 (coronavirus disease): Impacts on motor behavior
!
Santinelli et al.
2021
VOL.15
N.1
47 of 60
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,
BJMB! ! ! ! ! ! ! ! Special Issue:
!!!!!! Brazilian!Journal!of!Motor!Behavior! !!!!!!!!!!!!COVID-19 (coronavirus disease): Impacts on motor behavior
!
Santinelli et al.
2021
VOL.15
N.1
48 of 60
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,
BJMB! ! ! ! ! ! ! ! Special Issue:
!!!!!! Brazilian!Journal!of!Motor!Behavior! !!!!!!!!!!!!COVID-19 (coronavirus disease): Impacts on motor behavior
!
Santinelli et al.
2021
VOL.15
N.1
49 of 60
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
BJMB! ! ! ! ! ! ! ! Special Issue:
!!!!!! Brazilian!Journal!of!Motor!Behavior! !!!!!!!!!!!!COVID-19 (coronavirus disease): Impacts on motor behavior
!
Santinelli et al.
2021
VOL.15
N.1
50 of 60
points); mild difficulty (25 to 27 points); moderate difficulty (28 to 30 points); severe
difficulty sleeping (31 points or more).
1618
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.
BJMB$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Special Issue:
Brazilian Journal of Motor Behavior COVID-19 (coronavirus disease): Impacts on motor behavior
Santinelli et al.
2021
VOL.15
N.1
https://doi.org/10.20338/bjmb.v15i1.236
51 of 60
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