Community-based exercise programming for individuals with Parkinson’s disease: a qualitative study

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Allyson Jones, Marguerite Wieler, Victor E. Ezeugwu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6150621/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Parkinson’s disease (PD) is a progressive neurological disorder that significantly impacts individuals, their families, and the healthcare system. In addition to drug therapies and surgical interventions, exercise interventions have shown promise for improving both motor and non-motor symptoms in PD. This study aimed to investigate the perspectives of individuals with PD, care partners, and program providers about a community-based exercise program for PD. Methods Individuals with PD (Hoehn & Yahr stages I-III), on a stable medication regime, who had participated in a PD-specific community-based exercise program twice weekly for at least 12 weeks, along with their care partners and program providers were recruited to the study. Using a phenomenological qualitative study design, we conducted in-depth interviews with individuals with PD (n = 17), their care partners (n = 7), and program providers (n = 3). The interviews, lasting 20–50 minutes, were conducted from January 2024 to May 2024. Data were analyzed using interpretative phenomenology analysis framework, and findings were mapped onto a behaviour-change model. Two patient advisors and their care partners helped with data analysis and interpretation. Results Participants consistently identified the PD-specific nature of the program and the benefits of exercising in a group as key motivators for participation. Pre-program challenges included difficulties obtaining a diagnosis, coping with the impacts of PD (such as a sense of loss, adapting to non-motor symptoms, and managing medication side effects), and finding motivation to exercise (self-motivation or encouragement from family/friends). Post-program outcomes included symptom improvement and positive experiences with group exercise, including mutual motivation, community support, and reduced self-consciousness. These positive experiences led participants to recommend increasing community awareness of the program. Identified barriers to participation included transportation difficulties and cost. Conclusions The PD-specific exercise program was perceived as beneficial to overall health and wellness, providing physical, emotional, and social benefits. A lack of awareness about the significance of exercise in PD remains a critical challenge, highlighting the need for clinicians to take a more active role in educating patients about the benefits of exercise, an area that appears underemphasized. Parkinson’s disease Exercise Phenomenology Qualitative research Behaviour change Background Parkinson’s disease (PD) is recognized as the “fastest-growing neurological disorder” and a leading cause of disability worldwide [ 1 , 2 ], contributing to 5.8 million disability-adjusted life-years (DALYs) in 2019 [ 3 ]. Motor and non-motor symptoms associated with PD progressively worsen over time [ 1 , 4 ], leading to functional limitations and disability [ 1 , 2 , 4 – 6 ]. Drug and surgical therapies can provide symptomatic relief for motor symptoms (e.g. tremors, slowness, and stiffness) and some non-motor symptoms (e.g. sleep and mood disturbances) [ 7 – 10 ]. Non-drug treatments, such as exercise interventions, have also shown promise in improving both motor and non-motor symptoms and enhance quality of life in individuals with PD [ 11 – 13 ]. Emerging evidence suggests that exercise may have disease-modifying effects [ 14 , 15 ], with different forms and intensities of exercise interventions offering distinct benefits [ 16 ]. Aerobic and resistance training exercises, particularly when combined, have been shown to improve both physical and cognitive function, with recent evidence supporting multimodal exercise programs that integrate balance and cognitive training [ 17 – 20 ]. However, the evidence shows that long-term adherence is essential to maximize exercise benefits, as discontinuation of exercise, even for 6 months, results in regression of benefits [ 21 ]. Despite this, maintaining long-term adherence to exercise programs can be challenging due to barriers such as disease progression, changing response to medications, apathy, impact of motor and non-motor symptoms, fluctuation in motivation, and lack of awareness about exercise benefits [ 22 ]. Behaviour-change theories and models are valuable for understanding some of the factors that influence adherence and motivation to exercise. The capability, opportunity, motivation, and behavior (COM-B) model is particularly useful in examining health behaviours across various contexts, as it identifies facilitators and barriers to participation and adherence [ 23 – 25 ]. Qualitative research is essential for understanding patients' perspectives [ 26 ], yet relatively few studies [ 27 ] have explored the experiences of individuals with PD, their care partners, and program providers within PD-specific community-based exercise programs. This study addresses these gaps by exploring the experiences of individuals with PD, their care partners, and program providers about a PD-specific community-based exercise program and its impact on motor and non-motor symptoms, as well as quality of life. It also investigates motivating factors, barriers, and facilitators to exercise adherence through the lens of the COM-B framework. Findings may provide insights that can inform the design and implementation of more effective and sustainable community-based exercise programs for PD. Methods Study design and setting: A phenomenological qualitative approach was used [ 28 , 29 ], a research method that seeks to explore and interpret phenomena as consciously experienced by individuals [ 30 ]. The findings of this qualitative study were presented in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ), 32-item checklist designed to ensure thorough and transparent reporting of qualitative research [ 31 ]. The University of Alberta's Human Research Ethics Board approved this study (Ethics ID: Pro00122937). Participants and recruitment: Participants who attended a PD-specific community-based exercise program were purposively recruited between January and May 2024, based on age, sex, Hoehn and Yahr stages, and years since PD diagnosis [ 32 ]. Care partners who provided care and assistance, were also purposively sampled. Additionally, three staff members involved in program development and delivery were recruited to provide insights into program design, implementation, and opportunities for improvement. Inclusion criteria for individuals with PD included: a diagnosis of PD, age 50 years or older, Hoehn and Yahr stage of I–III, a self-reported stable drug regimen, and participation in the community-based exercise program under study for at least 12 weeks. Exclusion criteria included having another medical condition other than PD or being unable to communicate in English to be able to participate in the interviews. Community-based exercise program: The Parkinson Association of Alberta (PAA) offers both in-person and virtual PD-specific exercise programs through its Edmonton-based center, which serves the entire province. One such program is a 12-week, twice-weekly exercise intervention that combines structured and unstructured physical activity, with a focus on neuromuscular strength training. The program consists of 24 one-hour sessions, costing approximately $ 65 per hour. Participants in the exercise program are encouraged to attend all sessions, with no drop-in option available. However, participants may miss classes sporadically due to health issues, vacations or other personal reasons. The focus of the exercise program includes postural orientation, lower extremity strength, and functional exercises such as stepping lunges, step-ups, squats, and sit-to-stands. Led by an exercise specialist with expertise in PD, the program progresses in difficulty under supervision, incorporating manual resistance, weights, and unstable surfaces. Following a physiotherapist’s assessment, participants are assigned to one of the following groups based on their abilities: 1) Sit and Stand : Designed for individuals with PD who can ambulate but may need assistance. Exercises target strength, posture, and functional movements. 2) Power, Balance, and Reach : Includes exercises aimed at improving strength, balance, flexibility, and cognitive functions. 3) Circuit-Based Exercise Program : Structured into stations, this program combines aerobic and resistance exercises to enhance cardiovascular fitness, strength, and overall physical function. Additionally, an online class, named as Circuit 2 class is available via Zoom. Circuit 2 is a separate exercise program designed for participants who prefer to exercise from home or face challenges attending in person, such as transportation barriers. Data collection: Semi-structured interviews were conducted with participants either in-person (n = 15) at the PAA or via Zoom (n = 12) depending on their preference [ 33 ]. One researcher (AK) led participant interviews, while a second researcher (VEE) was involved with interviewing staff members. The research team had no role in the development or delivery of the exercise program and no affiliations with the PAA. Interview questions were collaboratively developed by researchers, patient advisors, and through a literature review and field observations at the PAA [ 34 – 36 ]. These questions explored participants’ views on exercise benefits and challenges, enrollment facilitators, and perceptions of the program. Interview guides for individuals with PD, care partners, and program providers are presented in Online Supplement Tables 1.1–1.3. Each interview was done in-person or by Zoom and lasted approximately 20–50 minutes. In one instance, a participant’s spouse contributed to the interview due to some difficulty with communication, otherwise participants and their care partners were interviewed separately. Researchers created field notes after each interview, reflecting on observations and key insights. Interviews were audio-recorded, transcribed using Otter.ai [ 37 ], and the generated transcripts were reviewed for accuracy by the researchers. Saturation was reached when additional interviews with individuals with PD no longer provided new insights to inform the themes. This occurred after the 15th interview, with two additional interviews reinforced existing themes [ 38 ]. Data Analysis: Data analysis followed the principles of interpretative phenomenological analysis (IPA) which takes an inductive approach [ 39 , 40 ]. The process began with multiple readings of transcripts to build familiarity with the data, followed by identifying significant statements and meaningful segments for coding. This bottom-up approach allowed themes to emerge organically from participants’ narratives. Using NVivo 14 software, transcripts were analyzed line by line, generating initial codes that captured participants’ experiences perceived experiences [ 41 ]. Themes identified from each transcript were refined and analyzed for recurring patterns across the dataset. This iterative process ensured that findings were deeply grounded in participants’ perspectives. To enhance rigor, two researchers (AK, VE) independently coded the transcripts to ensure consistency and reliability in the analysis. Patient advisors provided insights to validate the findings and ensure alignment with the lived experiences of individuals with PD and their care partners [ 42 ]. Senior researchers (CAJ, MW) contributed detailed feedback to refine the analytical process and ensure methodological rigor. Data triangulation was achieved by integrating multiple sources, including field notes, researcher observations during visits to the PAA, interviews with individuals with PD, care partners, and program providers [ 40 , 43 ]. The barriers and facilitators identified were mapped to the COM-B model as capabilities (physical and psychological factors), opportunities (physical and social factors), and motivations (automatic and reflective). Results A total of 27 interviews were conducted for this study (individuals with PD, n=17; care partners, n=7; program providers, n=3). The demographic characteristics of individuals with PD are presented in Table 1. The mean (standard deviation, SD) age of care partners was 70.6 (7.7) years and 70% were females. The program providers included two staff members with administrative roles (actively engaged with the PAA participants) and one exercise instructor. Fifteen individuals with PD attended in-person classes, while two participated in the virtual Circuit-2 class. One virtual participant living in the urban center chose online sessions due to transportation challenges, while the other was from rural Alberta. Although most participants renewed their memberships and attended regularly over the years, they occasionally missed sessions due to factors such as inclement weather, illness, or personal vacations. Table 1: Demographic characteristics of participants with PD Characteristic Mean ± SD [range] or n (%) Participants n = 17 Age, years 71.2 ± 9.3 [51-86] Duration of PD, years 4.3 ± 3.2 [1-11] Length of participation in exercises, years 2.8 ± 2.1 [0.25-3] Sex, males 10 (59%) Marital status Married Single 13 (76%) 4 (24%) Education University College/Diploma High school or below 13 (76%) 2 (12%) 2 (12%) Location Urban Rural 16 (94%) 1 (6%) Exercise group Circuit Power, balance, and Reach (PBR) Sit and stand 9 (53%) 4 (23.5%) 4 (23.5%) Exercise delivery In-person Virtual 15 (88%) 2 (12%) Themes: A total of seven themes were identified and categorized into two groups: pre-exercise and post-exercise themes, as shown in Tables 2.1 and 2.2. Each group of themes alongside their subthemes and supporting quotes are presented. Additionally, each theme was mapped to the COM-B model, where applicable, to indicate the presence or absence of relevant factors within the framework. Table 2.1 Pre-exercise themes Themes Subthemes Participant interviewed COM-B Mapping Individuals with PD Care-partners Theme 1: Challenges with obtaining a diagnosis N/A I went through a great deal of doctors and specialists before they found out what it was. (F: #08) He was diagnosed in 2016. And he had been having symptoms for at least five years before that, and we were trying to determine what his problem was. (Care-partner, F: #06) - Lack of physical opportunity Theme 2: Challenges of living with PD Sense of loss due to loss of gross motor and fine motor movements And then when I went to start knitting, I couldn't do it. (F: #03) N/A N/A Difficulties with adjusting to various non-motor symptoms (anxiety, depression, sleep, cognitive decline. The biggest things are my anxiety and sleeping right. If I could get a handle on that, I think it'd be in a lot better shape. (M: #13) N/A Psychological capability Dealing with medication side effects So, what I have learned was once you started taking the medication, this becomes lifetime thing, nobody told me that. (M: #01) N/A N/A Challenges as a partner More responsibilities, sadness/frustration, fear because of spouse disease N/A Ever since he has been diagnosed with PD, I've stopped doing a few things because I'm anxious about him. (Care-partner, F: #05) N/A Theme 3: Motivating factors to join the exercise program Personal factors Joined exercise program to learn about PD I wanted to see what I could do to help my condition, as opposed to what I couldn't do. (M: #15) N/A N/A Motivation (automatic) Social network and clinician referral My friends convinced me to join this program. (M: #07) Motivation (reflective) Care-partner’s motivational support So, my wife is very supportive. She's very much into exercise; she exercises more than I do. And so, there's my motivation. (M: #02) I certainly encouraged him, but I don't have to push him. No, he's very good at that. (Care-partner, F: #02) Motivation (reflective) Belief about exercise and its effect on wellbeing N/A I like that he exercises because this benefits me too down the road. We need to keep him active as long as we can. (Care-partner, F: #03) Motivation (reflective) Notes: N/A: not applicable or not available, F: female, M: male Table 2.2 Post-exercise themes Themes Subthemes Participant interviewed COMB Mapping individuals with PD Care-partners Program Providers Theme 4: Improvement of symptoms Improvement of motor symptoms I've had some mobility issues, had some issues with gait so coming to the exercise program, supplements strengthen my body, helping me. (M: #07) Coming here helped with self confidence in his mobility. (Care-partner, F: #02) We watch those who have a goal, especially when there is a physical goal, achieve it in a lot of cases, or at least maintain it. (Staff: #02) Physical opportunity Improvement in mood/quality of life I'd say it has helped with just overall happiness like energy. (M: #13) Her quality of life is better in terms of say concentration, outlook, and mobility. (Care-partner, M: #03) Some clients go away on vacation, they'll come back and say, I went in the pool with my grandkids, I swam in the ocean. And I couldn't have done that without the classes you do. That kind of stuff they can do, that has a direct impact on their life. (Staff: #03) Capability Improvement in other non-motor symptoms (pain has improved, disease has slowed down) So I have like, pretty bad back pain most of the time. I feel the best right after the class. So, it's well worth it. (M: #07) N/A -N/A N/A Theme 5: Benefits of exercise in group Motivate and learn from each other And you learn as much from the other participants too. Because everybody has their own issues. And it's amazing how many are similar. (F: #02) This is more than an exercise program, really, to be with other individuals and know they're going through similar experience helps a lot. (Care-Partner, M: #03) They really have become each other's support system, and their care partners, they have created this little informal group as well. (Staff: #01) Social opportunity Exercise in group helps build a community of supportive individuals I mean, this community here and my group fellows gave me the support when I was going through what I went through, it was truly vital. (F: #17) It has helped with his mood, in the sense that it's built his community. Like this exercise group, he couldn't live without these individuals. He would be lost without them. (Care-partner, F: #05) Because with Parkinson’s, everybody has different symptoms. So, to have that social group where there is no judgment because they're all going through something similar, and yet dissimilar. They are a resource (for each other). (Staff: #03) Social opportunity Feel less self conscious about my condition when I am around individuals with similar condition It's always good for me to see somebody else that has the same thing. You know what I mean? You just feel you're out there and there's nobody that even understands what you are going through but individuals here in this group are like me. (F: #08) N/A N/A Social opportunity Theme 6: Motivating factors Sustaining program attendance: Exercise instructor is friendly and well-informed Exercise instructor was a good motivator. I mean, I don't like exercise at all. He's the first guy that's been able to convince me to do it so. And I found it I feel really good after I do it, so. (M: #02) N/A N/A Motivation reflective Exercises are specific to PD I quickly learned is that the trainer had been trained in movements that were beneficial to those of us with Parkinson's. So that was one huge benefit. (F: #11) N/A The main focus I have because of Parkinson's, is strength. So power, strength, I also work on quick movements. I work on endurance, I make them work for heart rate, and I make them work on extension, that's the biggest thing. (Staff: #03) Physical opportunity Program provides information and knowledge about PD, friendly environment, feels welcoming Coming here helps because this place mainly as a resource is helpful. (M: #01) N/A When individuals with Parkinson’s comes to us, we provide them all information about this condition. (Staff: 02) Social/physical opportunity Exercise group has positively impact on their relationship N/A This program has helped our relationship, in a sense that I don't have to be there all the time for him. (Care-Partner, F: #07) N/A N/A Theme 7: Challenges in program participation and suggested improvements Transportation The biggest challenge is the building where they're in. I wouldn't go if I had to take a bus. (M: #02) It's a three-hour segment of your day that you're taking him to, for him to go to do the exercises. (Care-partner, F: #02) Getting here can sometimes be tricky for some of them, that's another barrier if they're not driving anymore. (Staff: #02) Lack of physical opportunity Cost of program And this program isn’t cheap. There are no specific tax benefits or something like that. (M: #15) N/A For some there's still a financial barrier but we also offer exercises on our YouTube channel. We also try and connect them to free opportunities that they're available, if they can't afford it. (Staff: #02) Lack of physical opportunity A tax deduction option could be included N/A It would be nice if we could use that as a deduction. This class is all out of pocket, and it's not cheap. (Care-Partner, F: #05) N/A Suggestion to improve physical opportunity Increase awareness about the community-based exercise program. But from a bigger perspective. I have often wondered if neurologists when they say you have Parkinson's, why don’t they tell you to come to this exercise program? (F: #17) N/A N/A Lack of physical opportunity Addition of new features to the program For some other diseases there is a lot of actual tracking., So if we have such tracking system here and could use it before medical appointments, that would be helpful. (M: #07) I would like to see more musical instruments being played in a program where they could come together. The musicians and play and, I mean, it doesn't have to be only just the Parkinson's, it could be the partners. (Care-partner, F: #03) N/A Suggestion to improve physical opportunity There should be more care partner support groups available N/A I don't think that the care partners are particularly involved in the online activity classes, but maybe there's should be some opportunity for us to say hello to each other. (Care-Partner, F: #07) N/A Suggestion to improve social opportunity Notes: N/A: not applicable or not available, F: female, M: male Pre exercise themes (Themes 1-3): Table 2.1 presents the themes that emerged as significant motivational factors influencing the participation of individuals with PD in exercise groups. Pre-exercise themes focus on motivators that encourage individuals to participate in the exercise program. Notably, nearly all (n=15). participants expressed motivation to engage in exercise programs. For some participants (n=5), their care partners played a crucial role in encouraging and supporting their exercise routines. One theme demonstrated that few individuals were directed to community resources for PD, such as the PAA, by their neurologist or physician (n=7), while many individuals independently discovered these resources (n=10). Additionally, two themes appeared, that were not directly related to the study's objectives. One of them was delay in diagnosis of PD and associated challenges. Both individuals with PD (n=14) and their care partners expressed that the diagnostic process for PD is often lengthy and frustrating. This prolonged period can be emotionally challenging due to the uncertainty involved. Furthermore, the delay in diagnosis indirectly causes delays in treatment and disease management, including exercise interventions. Another theme was the challenges associated with living with PD. Within this theme, a prominent subtheme emerged—a sense of loss. This subtheme was illustrated through unique narratives of participants (n=13) who described the loss of hobbies or aspects of their lifestyle. As PD causes a decline in fine motor and gross motor movements, many hobbies such as knitting, woodworking, and swimming may no longer be possible. This sense of loss can contribute to a decline in mood among individuals with PD. Post exercise themes : Table 2. 2. highlights the post-exercise themes. The four themes identified encompass the benefits of exercise program participation, the motivational factors that promote long-term adherence, and the barriers and suggestions for improvements reported by both individuals with PD, care partners, and program-providers. A brief description of each theme is provided below. Theme 4: Improvement of symptoms: Most participants with PD reported overall subjective improvement in mobility, strength, and endurance. Additionally, eight participants noted enhanced flexibility and reduced rigidity, while five participants observed better balance since joining the exercise program. Nine participants reported improved mood since joining the exercise program, while six participants noted increased confidence in their ability to walk and move and felt more hopeful about their mobility. Six participants reported overall improved pain since they joined the exercise program, while five of them perceived that participation in the exercise program may have played a role in slowing down the progression of the disease. Six care-partners reported that the program helped their partners to stay active and has enhanced their mobility confidence. One care-partner emphasized that the exercise increased strength. Some care-partners mentioned that participating in the exercise program uplifted their partner’s mood and had a positive effect on their quality of life. Program providers reported that they often observed a noticeable improvement in overall mobility of the individuals with PD after a few months of joining exercise program. Program providers also reported that they often receive feedback from participants that the program helped to bring a positive change in quality of life of individuals with PD. Theme 5: Benefits of exercise in groups: Fourteen participants with PD reported that group exercise provides mutual motivation to maintain physical activity. When exercises were challenging, emotional support from peers helped maintain self-esteem, fostering a supportive and encouraging environment. Participants highlighted that the sense of community from the group is crucial for their well-being. The exercise program's community helped them discuss challenging issues, such as diverse symptoms and medication side effects. Many noted that this sense of community indirectly improved their mood and overall well-being. Participants expressed that they feel less self-conscious when exercising with individuals who have the same disease, compared to exercising with a non-PD population. This shared experience is an important motivating factor that sustains their ongoing participation in the exercise program. Five care partners noted that the exercise group motivated their partners, as it included others with similar disease severity, fostering mutual encouragement and shared learning. Five care-partners stated that individuals in the exercise group understand their partner’s health condition, making them happy that their partner is finally in a place where they can express their problems, feel heard and understood. Program providers also expressed that the community these individuals with PD have built play a vital role in terms of providing them support and motivation. Program providers mentioned that individuals with PD provide unwavering emotional support to each other. Theme 6: Motivating factors sustaining program attendance: Fifteen participants with PD (including both in-person and online classes) appreciated the instructor's PD-specific knowledge and encouragement in fostering a supportive atmosphere. Thirteen participants valued the exercise program's design in enhancing their health and quality of life. Five care partners noted its positive impact on their relationships and respite from responsibilities. Providers emphasized the program's tailored services for different stages of PD, including education and exercise. Participants appreciated the PAA for providing PD-specific information, program management, and a supportive environment. Theme 7: Challenges in program participation and suggested improvements: Participants generally reported few challenges with program participation. However, seven participants with PD identified commuting as a significant barrier, often relying on partners due to their inability to drive. Although three participants noted that transportation is not currently an issue, they acknowledged it could become a challenge in the future possibly due to deteriorating health status. Both care partners and program providers identified transportation as a challenge, with care partners specifically reporting difficulties in transporting their partners, particularly during adverse weather. Nevertheless, they recognized the program's importance and ensured attendance. Five participants identified the program's cost as a financial challenge but deemed the benefits substantial enough to justify the expense, emphasizing the positive impact on their health. After learning that cost was a concern for participants, providers acknowledged it as a potential barrier to participation. To address the financial burden of out-of-pocket expenses, a few participants suggested tax deduction options, as the program is not covered by government funding. Participants made various suggestions, including some additional recommendations that did not emerge as main themes. Nine participants recommended enhancements to the PAA program, such as tracking symptoms to monitor disease progression, incorporating dance and music classes, providing access to diet consultants, organizing more social events, and including tailored cognitive exercises. Some of these existed previously but may have been trimmed down due to funding barriers. Care partners emphasized the necessity for additional support groups specific to care partners, both in-person and online, to foster mutual support among care partners. They also supported the addition of music and dance classes for individuals with PD and their care partners. Discussion In this study, people with PD perceived a PD-specific community-based exercise program as a positive experience, noting improvements in physical symptoms and psychological well-being. Seven themes, classified as pre-exercise and post-exercise, show program benefits, challenges, motivations, and perceived changes in quality of life. These themes provide valuable insights into the PD journey from the perspectives of individuals with PD, their care partners, and program providers. Pre-exercise themes primarily highlight the motivational factors that encouraged individuals with PD to join the exercise program. According to the COM-B model, motivation—both automatic and reflective—is essential for behaviour change [ 24 ]. Our findings showed that participants were intrinsically motivated to exercise [ 24 , 25 ], demonstrating automatic motivation [ 25 ]. While participants showed automatic motivation, care partners ongoing support contributed to reflective motivation. This combined motivation is crucial for long-term program adherence [ 24 , 25 ]. Furthermore, our study identifies that the extended period before diagnosis (a prerequisite for program enrollment) and the associated uncertainty often led to mental frustration for both individuals with PD and their care partners, aligning with previous research [ 44 ]. Within the COM-B model, this may indicate a lack of opportunity. The diverse symptoms of PD can disrupt hobbies and alter lifestyles, leading to a sense of loss. This, in turn, often contributes to a decline in mood which may already be part of the disease process - negatively impacting quality of life for individuals with PD [ 45 , 46 ]. The post-exercise themes in this study show that participants perceived several benefits from participating in a PD-specific community-based exercise program. Multicomponent programs incorporating aerobic, stretching, resistance, and cognitive exercises play an important role in improving quality of life, mobility, pain, and mood in individuals with PD [ 46 – 49 ]. These programs also positively impact relationships between individuals with PD and their partners [ 50 , 51 ], an important, yet underemphasized aspect of PD. Adherence to the exercise program was influenced by the nature of the PD-specific exercises, supportive instructors, and the group setting [ 22 , 52 ]. Social interactions and community support provided by the PAA were crucial for enhancing mood and well-being [ 53 – 55 ]. These factors provide both physical and social opportunities, supporting long term adherence, as indicated in the COM-B model. In our study, grouping individuals based on disease severity made them feel “less self-conscious” and more motivated to exercise with people at same level of functioning in line with the capability aspect of the COM-B model [ 24 ].This suggests that the perception of how people with PD engage in exercise may vary with disease severity [ 56 ], highlighting the psychological aspect of capability. Assessing the severity of the condition before group assignment may be essential for participation and long-term adherence to the exercise program. Notably, in PAA, pre-assignment screenings ensured appropriate group placements, which participants found satisfactory, underscoring the significance of physical capability. Our findings demonstrate that the COM-B model provides a valuable framework for understanding the factors that support long-term adherence to community-based exercise programs for individuals with PD. Tailoring exercise programs based on disease severity emerged as a critical factor for engagement. Participants who underwent physiotherapist-led assessments were placed in appropriate groups, which enhanced both their physical and psychological confidence in exercising. This personalized approach may improve long-term adherence by ensuring that exercises are appropriately challenging yet manageable [ 24 , 56 , 57 ]. Opportunities for participation were influenced by both physical and social factors. Access to exercise equipment, knowledgeable instructors, and structured programs encouraged consistent engagement [ 24 , 52 , 56 ]. Group-based activities fostered social connections, which participants found highly motivating. However, logistical barriers such as transportation challenges, program costs, and limited awareness of available community resources may restrict participation, highlighting areas for improvement [ 22 , 58 ]. Motivation played a central role, with participants demonstrating an inherent drive to stay active (automatic motivation). This was further reinforced by structured goal-setting, educational support, and encouragement from both care partners and exercise leaders (reflective motivation) [ 24 , 52 ]. The combination of these motivational factors likely contributed to sustained participation and overall improvements in well-being [ 52 , 55 , 57 ]. By addressing these elements—ensuring appropriate exercise tailoring, improving accessibility, and fostering motivation—community-based exercise programs can better support individuals with PD, enhancing both physical function and quality of life. Also, our study showed that PD-specific community-based programs can positively impact the relationships of individuals with PD and their partners, which may play a role in improving their mental health. A limitation of this study is that only people who regularly attended the program were interviewed. Different perspectives may be captured by those who dropped out of the program or who were not interested in exercising. Factors such as lack of social support, worsening of PD-related symptoms, and lack of awareness of the role of exercise in PD have been previously documented as contributing to a lack of interest in exercise among individuals with PD [ 22 ]. Conclusion This study explored perspectives on a PD-specific community-based exercise program for individuals with PD, identifying benefits and barriers using the COM-B model. Both automatic and reflective motivation are essential for sustained participation. Assessing baseline capability and placing individuals in appropriate groups support long-term adherence. Participants reported that group exercise fosters a sense of community, while tailored programming enhances engagement in a community-based exercise program. However, barriers such as transportation, cost, and limited awareness of the benefits of exercise remain challenges. Addressing these factors through targeted education and accessible programming may optimize participation and long-term health outcomes in PD. Future research should examine the perspectives of people with PD and their care partners who do not participate in PD-specific community-based exercise programs to identify barrier to participation. Declarations Human Ethics and Consent to Participate : The University of Alberta's Human Research Ethics Board approved this study (Ethics ID: Pro00122937). All participants provided written informed consent before enrollment. Funding : AK received Mitacs Accelerate studentship (# IT37143). The funding body had no role in the study's design, collection, analysis, and interpretation of data, or in writing the manuscript. Availability of data and materials : All data generated or analysed during this study are included in this article and its supplementary information files. Clinical Trial Number : Not applicable. Consent for publication : Not applicable. Competing interests : The authors declare that they have no competing interests. Authors’ contributions : AK and VE conducted and analyzed the participant interviews. All authors read and approved the final manuscript. References Dorsey ER, Bloem BR. The Parkinson Pandemic—A Call to Action. JAMA Neurol. 2018;75:9. 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Barriers and facilitators to exercise adherence in community-dwelling older adults: A mixed-methods systematic review using the COM-B model and Theoretical Domains Framework. Int J Nurs Stud. 2024;157:104808. Webb J, Baker A, Palmer T, Hall A, Ahlquist A, Darlow J, et al. The barriers and facilitators to physical activity in people with a musculoskeletal condition: A rapid review of reviews using the COM-B model to support intervention development. Public Health Pract. 2022;3:100250. Aspers P, Corte U. What is Qualitative in Qualitative Research. Qual Sociol. 2019;42:139–60. Hunter H, Lovegrove C, Haas B, Freeman J, Gunn H. Experiences of people with Parkinson’s disease and their views on physical activity interventions: a qualitative systematic review. JBI Database Syst Rev Implement Rep. 2019;17:548–613. John W, Creswell CNP. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Guetterman TC, Fetters MD, Creswell JW. 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Råheim M, Magnussen LH, Sekse RJT, Lunde Å, Jacobsen T, Blystad A. Researcher–researched relationship in qualitative research: Shifts in positions and researcher vulnerability. Int J Qual Stud Health Well-being. 2016;11:30996. Otter.ai. (2024). Interview transcripts related to PD Study. Retrieved from https://otter.ai/ Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2022;292:114523. Tindall LJA, Smith P, Flower, Larkin M. (2009), Interpretative Phenomenological Analysis: Theory, Method and Research . Qual Res Psychol. 2009;6:346–7. Smith JA. Interpretative phenomenological analysis: Getting at lived experience. J Posit Psychol. 2017;12:303–4. Mortelmans D. Analyzing Qualitative Data Using NVivo. The Palgrave Handbook of Methods for Media Policy Research. Cham: Springer International Publishing; 2019. pp. 435–50. Jackson T, Pinnock H, Liew SM, Horne E, Ehrlich E, Fulton O, et al. Patient and public involvement in research: from tokenistic box ticking to valued team members. BMC Med. 2020;18:79. Noble H, Smith J. Issues of validity and reliability in qualitative research. Evid Based Nurs. 2015;18:34–5. Krieger T, Jozwiak L, Ebersbach G, Suess T, Falkenburger B, Feige T, et al. Exploring the lived experiences of individuals with Parkinson’s disease and their relatives: insights into care provision experiences, disease management support, self-management strategies, and future needs in Germany (qualitative study). BMC Neurol. 2024;24:208. Islam SS, Neargarder S, Kinger SB, Fox-Fuller JT, Salazar RD, Cronin-Golomb A. Perceived stigma and quality of life in Parkinson’s disease with additional health conditions. Gen Psychiatr. 2022;35:e100653. Ahern L, Curtin C, Timmons S, Lamb SE, McCullagh R. Exercise… to Me, It’s Freedom:Motivation, Support, and Self-Management to Keep Physically Active with Parkinson’s Disease: A Qualitative Study. Geriatrics. 2024;9:92. Langeskov-Christensen M, Franzén E, Grøndahl Hvid L, Dalgas U. Exercise as medicine in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2024;95:1077–88. Duchesne C, Lungu O, Nadeau A, Robillard ME, Boré A, Bobeuf F, et al. Enhancing both motor and cognitive functioning in Parkinson’s disease: Aerobic exercise as a rehabilitative intervention. Brain Cogn. 2015;99:68–77. Lamotte G, Skender E, Rafferty MR, David FJ, Sadowsky S, Corcos DM. Effects of Progressive Resistance Exercise Training on the Motor and Nonmotor Features of Parkinson’s Disease: A Review. Kinesiol Rev. 2015;4:11–27. Dekawaty A, Malini H, Fernandes F. Family experiences as a caregiver for patients with Parkinson’s disease: a qualitative study. J Res Nurs. 2019;24:317–27. Glover L, Dixon C, Kobylecki C, Eccles FJR. Parkinson’s and the couple relationship: a qualitative meta-synthesis. Aging Ment Health. 2023;27:2420–9. Crizzle AM, Newhouse IJ. Themes Associated With Exercise Adherence in Persons With Parkinson’s Disease: A Qualitative Study. Occup Ther Health Care. 2012;26:174–86. Spink KS, Wilson KS, Priebe CS. Groupness and adherence in structured exercise settings. Group Dynamics: Theory Res Pract. 2010;14:163–73. Ferrusola-Pastrana A, Fullerton CL, Meadows SN. Group-based exercise for Parkinson’s: a qualitative study of participants and partners’ perceptions of an exercise class delivered through a community-university collaboration. BMC Geriatr. 2024;24:488. Cleary AS, Rossi A, States RA. Parkinson’s Disease: Exploring Motives for Long-Term Adherence to a Group Exercise Program. Rehabilitation Nurs. 2020;45:131–9. Flynn A, Dennis S, Preston E, Canning CG, Allen NE. Exercising with Parkinson’s: The good, the bad and the need for support to keep exercising. A qualitative study. Clin Rehabil. 2022;36:1332–41. Williams TL, Hunt ER, Papathomas A, Smith B. Exercise is medicine? Most of the time for most; but not always for all. Qual Res Sport Exerc Health. 2018;10:441–56. Ellis T, Boudreau JK, DeAngelis TR, Brown LE, Cavanaugh JT, Earhart GM, et al. Barriers to Exercise in People With Parkinson Disease. Phys Ther. 2013;93:628–36. Additional Declarations No competing interests reported. Supplementary Files COREQChecklistSupportingfile.pdf Interviewguidequestions.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6150621","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":427057640,"identity":"566ca02d-44e0-4ee5-8d99-7e51a34e102f","order_by":0,"name":"Aiza Khan","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Aiza","middleName":"","lastName":"Khan","suffix":""},{"id":427057641,"identity":"0def8c8e-02a3-4c2d-93a3-07d8f72913b4","order_by":1,"name":"C. 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Ezeugwu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3OsQqCQBzH8RPhXI5cFSlf4URokehVEiGXgh7hpmsJWustnJwaLg50EVxt06W5hsJBIt2aTtuC7rMd/L/8DgBJ+mETAFT6XeICoHQJHp74ZHCi6zwxH5SHUXqm5f3U2EDjpTAxSbK0xpSvo8zfOocrdghaiqfweTe1zLhNmE8txLBCjJ7fzbn+7JIQ5xW1GobnxNBu4hWIoHmP+QIX7Qpg2CcGEq8YGXQ95RU6x6LaOjvmBhStNsJE3/PqUmeePcqDpKzZZLbX0kiYdFT0+YK99y2lHnIlSZL0v97T6EkyjGcfDAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Alberta","correspondingAuthor":true,"prefix":"","firstName":"Victor","middleName":"E.","lastName":"Ezeugwu","suffix":""}],"badges":[],"createdAt":"2025-03-04 04:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6150621/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6150621/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78339620,"identity":"540dc0ce-dad1-49a4-80a6-49b6decf98cd","added_by":"auto","created_at":"2025-03-12 08:29:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":888739,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6150621/v1/b0b3c51d-66f0-4cc8-9cf5-2e47bafec9db.pdf"},{"id":78338350,"identity":"f24450da-e547-4bf4-930e-5addb88c3a24","added_by":"auto","created_at":"2025-03-12 08:21:37","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":452218,"visible":true,"origin":"","legend":"","description":"","filename":"COREQChecklistSupportingfile.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6150621/v1/8cb6ae9e890fafdf7fe052f3.pdf"},{"id":78338348,"identity":"ed1c7021-09cb-4b42-aa5c-d682e97c9f07","added_by":"auto","created_at":"2025-03-12 08:21:37","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":21808,"visible":true,"origin":"","legend":"","description":"","filename":"Interviewguidequestions.docx","url":"https://assets-eu.researchsquare.com/files/rs-6150621/v1/36dbe617df021685190e43fa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community-based exercise programming for individuals with Parkinson’s disease: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eParkinson\u0026rsquo;s disease (PD) is recognized as the \u0026ldquo;fastest-growing neurological disorder\u0026rdquo; and a leading cause of disability worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], contributing to 5.8\u0026nbsp;million disability-adjusted life-years (DALYs) in 2019 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Motor and non-motor symptoms associated with PD progressively worsen over time [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], leading to functional limitations and disability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Drug and surgical therapies can provide symptomatic relief for motor symptoms (e.g. tremors, slowness, and stiffness) and some non-motor symptoms (e.g. sleep and mood disturbances) [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Non-drug treatments, such as exercise interventions, have also shown promise in improving both motor and non-motor symptoms and enhance quality of life in individuals with PD [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmerging evidence suggests that exercise may have disease-modifying effects [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], with different forms and intensities of exercise interventions offering distinct benefits [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Aerobic and resistance training exercises, particularly when combined, have been shown to improve both physical and cognitive function, with recent evidence supporting multimodal exercise programs that integrate balance and cognitive training [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, the evidence shows that long-term adherence is essential to maximize exercise benefits, as discontinuation of exercise, even for 6 months, results in regression of benefits [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Despite this, maintaining long-term adherence to exercise programs can be challenging due to barriers such as disease progression, changing response to medications, apathy, impact of motor and non-motor symptoms, fluctuation in motivation, and lack of awareness about exercise benefits [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBehaviour-change theories and models are valuable for understanding some of the factors that influence adherence and motivation to exercise. The capability, opportunity, motivation, and behavior (COM-B) model is particularly useful in examining health behaviours across various contexts, as it identifies facilitators and barriers to participation and adherence [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Qualitative research is essential for understanding patients' perspectives [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], yet relatively few studies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] have explored the experiences of individuals with PD, their care partners, and program providers within PD-specific community-based exercise programs.\u003c/p\u003e \u003cp\u003eThis study addresses these gaps by exploring the experiences of individuals with PD, their care partners, and program providers about a PD-specific community-based exercise program and its impact on motor and non-motor symptoms, as well as quality of life. It also investigates motivating factors, barriers, and facilitators to exercise adherence through the lens of the COM-B framework. Findings may provide insights that can inform the design and implementation of more effective and sustainable community-based exercise programs for PD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eA phenomenological qualitative approach was used [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], a research method that seeks to explore and interpret phenomena as consciously experienced by individuals [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The findings of this qualitative study were presented in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ), 32-item checklist designed to ensure thorough and transparent reporting of qualitative research [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The University of Alberta's Human Research Ethics Board approved this study (Ethics ID: Pro00122937).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and recruitment:\u003c/h3\u003e\n\u003cp\u003eParticipants who attended a PD-specific community-based exercise program were purposively recruited between January and May 2024, based on age, sex, Hoehn and Yahr stages, and years since PD diagnosis [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Care partners who provided care and assistance, were also purposively sampled. Additionally, three staff members involved in program development and delivery were recruited to provide insights into program design, implementation, and opportunities for improvement. Inclusion criteria for individuals with PD included: a diagnosis of PD, age 50 years or older, Hoehn and Yahr stage of I\u0026ndash;III, a self-reported stable drug regimen, and participation in the community-based exercise program under study for at least 12 weeks. Exclusion criteria included having another medical condition other than PD or being unable to communicate in English to be able to participate in the interviews.\u003c/p\u003e\n\u003ch3\u003eCommunity-based exercise program:\u003c/h3\u003e\n\u003cp\u003eThe Parkinson Association of Alberta (PAA) offers both in-person and virtual PD-specific exercise programs through its Edmonton-based center, which serves the entire province. One such program is a 12-week, twice-weekly exercise intervention that combines structured and unstructured physical activity, with a focus on neuromuscular strength training. The program consists of 24 one-hour sessions, costing approximately \u003cspan\u003e$\u003c/span\u003e65 per hour. Participants in the exercise program are encouraged to attend all sessions, with no drop-in option available. However, participants may miss classes sporadically due to health issues, vacations or other personal reasons. The focus of the exercise program includes postural orientation, lower extremity strength, and functional exercises such as stepping lunges, step-ups, squats, and sit-to-stands. Led by an exercise specialist with expertise in PD, the program progresses in difficulty under supervision, incorporating manual resistance, weights, and unstable surfaces. Following a physiotherapist\u0026rsquo;s assessment, participants are assigned to one of the following groups based on their abilities: 1) \u003cb\u003eSit and Stand\u003c/b\u003e: Designed for individuals with PD who can ambulate but may need assistance. Exercises target strength, posture, and functional movements. 2) \u003cb\u003ePower, Balance, and Reach\u003c/b\u003e: Includes exercises aimed at improving strength, balance, flexibility, and cognitive functions. 3) \u003cb\u003eCircuit-Based Exercise Program\u003c/b\u003e: Structured into stations, this program combines aerobic and resistance exercises to enhance cardiovascular fitness, strength, and overall physical function. Additionally, an online class, named as \u003cem\u003eCircuit 2\u003c/em\u003e class is available via Zoom. \u003cem\u003eCircuit 2\u003c/em\u003e is a separate exercise program designed for participants who prefer to exercise from home or face challenges attending in person, such as transportation barriers.\u003c/p\u003e\n\u003ch3\u003eData collection:\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted with participants either in-person (n\u0026thinsp;=\u0026thinsp;15) at the PAA or via Zoom (n\u0026thinsp;=\u0026thinsp;12) depending on their preference [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. One researcher (AK) led participant interviews, while a second researcher (VEE) was involved with interviewing staff members. The research team had no role in the development or delivery of the exercise program and no affiliations with the PAA. Interview questions were collaboratively developed by researchers, patient advisors, and through a literature review and field observations at the PAA [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. These questions explored participants\u0026rsquo; views on exercise benefits and challenges, enrollment facilitators, and perceptions of the program. Interview guides for individuals with PD, care partners, and program providers are presented in Online Supplement Tables\u0026nbsp;1.1\u0026ndash;1.3. Each interview was done in-person or by Zoom and lasted approximately 20\u0026ndash;50 minutes. In one instance, a participant\u0026rsquo;s spouse contributed to the interview due to some difficulty with communication, otherwise participants and their care partners were interviewed separately. Researchers created field notes after each interview, reflecting on observations and key insights. Interviews were audio-recorded, transcribed using Otter.ai [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and the generated transcripts were reviewed for accuracy by the researchers. Saturation was reached when additional interviews with individuals with PD no longer provided new insights to inform the themes. This occurred after the 15th interview, with two additional interviews reinforced existing themes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eData analysis followed the principles of interpretative phenomenological analysis (IPA) which takes an inductive approach [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The process began with multiple readings of transcripts to build familiarity with the data, followed by identifying significant statements and meaningful segments for coding. This bottom-up approach allowed themes to emerge organically from participants\u0026rsquo; narratives. Using NVivo 14 software, transcripts were analyzed line by line, generating initial codes that captured participants\u0026rsquo; experiences perceived experiences [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Themes identified from each transcript were refined and analyzed for recurring patterns across the dataset. This iterative process ensured that findings were deeply grounded in participants\u0026rsquo; perspectives. To enhance rigor, two researchers (AK, VE) independently coded the transcripts to ensure consistency and reliability in the analysis. Patient advisors provided insights to validate the findings and ensure alignment with the lived experiences of individuals with PD and their care partners [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Senior researchers (CAJ, MW) contributed detailed feedback to refine the analytical process and ensure methodological rigor. Data triangulation was achieved by integrating multiple sources, including field notes, researcher observations during visits to the PAA, interviews with individuals with PD, care partners, and program providers [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The barriers and facilitators identified were mapped to the COM-B model as capabilities (physical and psychological factors), opportunities (physical and social factors), and motivations (automatic and reflective).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 27 interviews were conducted for this study (individuals with PD, n=17; care partners, n=7; program providers, n=3). The demographic characteristics of individuals with PD are presented in Table 1. The mean (standard deviation, SD) age of care partners was 70.6 (7.7) years and 70% were females. The program providers included two staff members with administrative roles (actively engaged with the PAA participants) and one exercise instructor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFifteen individuals with PD attended in-person classes, while two participated in the virtual \u003cem\u003eCircuit-2\u003c/em\u003e class. One virtual participant living in the urban center chose online sessions due to transportation challenges, while the other was from rural Alberta. Although most participants renewed their memberships and attended regularly over the years, they occasionally missed sessions due to factors such as inclement weather, illness, or personal vacations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eDemographic characteristics of participants with PD\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD [range] or n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eParticipants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003en = 17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eAge, years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e71.2 \u0026plusmn; 9.3 [51-86]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eDuration of PD, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 3.2\u0026nbsp;[1-11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eLength of participation in exercises, years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e2.8 \u0026plusmn; 2.1 [0.25-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eSex, males\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e10 (59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eMarital status\u0026nbsp;\u003cbr\u003e\u0026nbsp; Married\u0026nbsp;\u003cbr\u003e\u0026nbsp; Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (76%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;4 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;University\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;College/Diploma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;High school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (76%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;2 (12%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;2 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Urban\u003cbr\u003e\u0026nbsp; Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (94%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;1 (6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eExercise group\u003cbr\u003e\u0026nbsp; Circuit\u003cbr\u003e\u0026nbsp; Power, balance, and Reach (PBR)\u003cbr\u003e\u0026nbsp; Sit and stand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (53%)\u003c/p\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eExercise delivery\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;In-person\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Virtual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (88%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (12%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of seven themes were identified and categorized into two groups: pre-exercise and post-exercise themes, as shown in Tables 2.1 and 2.2. Each group of themes alongside their subthemes and supporting quotes are presented. Additionally, each theme was mapped to the COM-B model, where applicable, to indicate the presence or absence of relevant factors within the framework.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.1 Pre-exercise themes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant interviewed\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMapping\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eIndividuals with PD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eCare-partners\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;Theme 1:\u003c/p\u003e\n \u003cp\u003eChallenges with obtaining a diagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eI went through a great deal of doctors and specialists before they found out what it was. (F: #08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eHe was diagnosed in 2016. And he had been having symptoms for at least five years before that, and we were trying to determine what his problem was. (Care-partner, F: #06)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eLack of physical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTheme 2:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Challenges of living with PD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eSense of loss due to loss of gross motor and fine motor movements\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eAnd then when I went to start knitting, I couldn\u0026apos;t do it. (F: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eDifficulties with adjusting to various non-motor symptoms (anxiety, depression, sleep, cognitive decline.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eThe biggest things are my anxiety and sleeping right. If I could get a handle on that, I think it\u0026apos;d be in a lot better shape. (M: #13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePsychological capability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;Dealing with medication side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eSo, what I have learned was once you started taking the medication, this becomes lifetime thing, nobody told me that. (M: #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eChallenges as a partner\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMore responsibilities, sadness/frustration, fear because of spouse disease \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eEver since he has been diagnosed with PD, I\u0026apos;ve stopped doing a few things because I\u0026apos;m anxious about him. (Care-partner, F: #05)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTheme 3:\u003c/p\u003e\n \u003cp\u003eMotivating factors to join the exercise program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ePersonal factors\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eJoined exercise program to learn about PD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eI wanted to see what I could do to help my condition, as opposed to what I couldn\u0026apos;t do. (M: #15)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003cp\u003e(automatic)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSocial network and clinician referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eMy friends convinced me to join this program. (M: #07)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003cp\u003e(reflective)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCare-partner\u0026rsquo;s motivational support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eSo, my wife is very supportive. She\u0026apos;s very much into exercise; she exercises more than I do. And so, there\u0026apos;s my motivation. (M: #02)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eI certainly encouraged him, but I don\u0026apos;t have to push him. No, he\u0026apos;s very good at that. (Care-partner, F: #02)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003cp\u003e(reflective)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eBelief about exercise and its effect on wellbeing \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eI like that he exercises because this benefits me too down the road. We need to keep him active as long as we can. (Care-partner, F: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003cp\u003e(reflective)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: N/A: not applicable or not available, F: female, M: male\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.2 Post-exercise themes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant interviewed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOMB\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMapping\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;individuals with PD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCare-partners\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProgram\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProviders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTheme 4: Improvement of symptoms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprovement of motor symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI\u0026apos;ve had some mobility issues, had some issues with gait so coming to the exercise program, supplements strengthen my body, helping me. (M: #07)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComing here helped with self confidence in his mobility. (Care-partner, F: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;We watch those who have a goal, especially when there is a physical goal, achieve it in a lot of cases, or at least maintain it. (Staff: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprovement in mood/quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eI\u0026apos;d say it has helped with just overall happiness like energy. (M: #13)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHer quality of life is better in terms of say concentration, outlook, and mobility. (Care-partner, M: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSome clients go away on vacation, they\u0026apos;ll come back and say, I went in the pool with my grandkids, I swam in the ocean. And I couldn\u0026apos;t have done that without the classes you do. That kind of stuff they can do, that has a direct impact on their life. (Staff: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCapability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprovement in other non-motor symptoms (pain has improved, disease has slowed down)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSo I have like, pretty bad back pain most of the time. I feel the best right after the class. So, it\u0026apos;s well worth it. (M: #07)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-N/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTheme 5:\u003c/p\u003e\n \u003cp\u003eBenefits of exercise in group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMotivate and learn from each other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnd you learn as much from the other participants too. Because everybody has their own issues. And it\u0026apos;s amazing how many are similar. (F: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThis is more than an exercise program, really, to be with other individuals and know they\u0026apos;re going through similar experience helps a lot. (Care-Partner, M: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThey really have become each other\u0026apos;s support system, and their care partners, they have created this little informal group as well. (Staff: #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Social opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExercise in group helps build a community of supportive individuals\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI mean, this community here and my group fellows gave me the support when I was going through what I went through, it was truly vital. (F: #17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt has helped with his mood, in the sense that it\u0026apos;s built his community. Like this exercise group, he couldn\u0026apos;t live without these individuals. He would be lost without them. (Care-partner, F: #05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBecause with Parkinson\u0026rsquo;s, everybody has different symptoms. So, to have that social group where there is no judgment because they\u0026apos;re all going through something similar, and yet dissimilar. They are a resource (for each other). (Staff: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFeel less self conscious about my condition when I am around individuals with similar condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt\u0026apos;s always good for me to see somebody else that has the same thing. You know what I mean? You just feel you\u0026apos;re out there and there\u0026apos;s nobody that even understands what you are going through but individuals here in this group are like me. (F: #08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eTheme 6:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMotivating factors Sustaining program attendance:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExercise instructor is friendly and well-informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExercise instructor was a good motivator. I mean, I don\u0026apos;t like exercise at all. He\u0026apos;s the first guy that\u0026apos;s been able to convince me to do it so. And I found it I feel really good after I do it, so. (M: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003cp\u003ereflective\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExercises are specific to PD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI quickly learned is that the trainer had been trained in movements that were beneficial to those of us with Parkinson\u0026apos;s. So that was one huge benefit. (F: #11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe main focus I have because of Parkinson\u0026apos;s, is strength. So power, strength, I also work on quick movements. I work on endurance, I make them work for heart rate, and I make them work on extension, that\u0026apos;s the biggest thing. (Staff: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProgram provides information and knowledge about PD, friendly environment, feels welcoming\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComing here helps because this place mainly as a resource is helpful. (M: #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWhen individuals with Parkinson\u0026rsquo;s comes to us, we provide them all information about this condition. (Staff: 02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial/physical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExercise group has positively impact on their relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThis program has helped our relationship, in a sense that I don\u0026apos;t have to be there all the time for him. (Care-Partner, F: #07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eTheme 7:\u003c/p\u003e\n \u003cp\u003eChallenges in program participation and suggested improvements\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransportation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe biggest challenge is the building where they\u0026apos;re in. I wouldn\u0026apos;t go if I had to take a bus. (M: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt\u0026apos;s a three-hour segment of your day that you\u0026apos;re taking him to, for him to go to do the exercises. (Care-partner, F: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGetting here can sometimes be tricky for some of them, that\u0026apos;s another barrier if they\u0026apos;re not driving anymore. (Staff: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of physical opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCost of program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnd this program isn\u0026rsquo;t cheap. There are no specific tax benefits or something like that. (M: #15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFor some there\u0026apos;s still a financial barrier but we also offer exercises on our YouTube channel. We also try and connect them to free opportunities that they\u0026apos;re available, if they can\u0026apos;t afford it. (Staff: #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of physical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA tax deduction option could be included\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt would be nice if we could use that as a deduction. This class is all out of pocket, and it\u0026apos;s not cheap. (Care-Partner, \u0026nbsp;F: #05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuggestion to improve physical opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIncrease awareness about the community-based exercise program.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBut from a bigger perspective. I have often wondered if neurologists when they say you have Parkinson\u0026apos;s, why don\u0026rsquo;t they tell you to come to this exercise program? (F: #17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of physical opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAddition of new features to the program\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFor some other diseases there is a lot of actual tracking., So if we have such tracking system here and could use it before medical appointments, that would be helpful. (M: #07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI would like to see more musical instruments being played in a program where they could come together. The musicians and play and, I mean, it doesn\u0026apos;t have to be only just the Parkinson\u0026apos;s, it could be the partners. (Care-partner, F: #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuggestion to improve physical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThere should be more care partner support groups available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI don\u0026apos;t think that the care partners are particularly involved in the online activity classes, but maybe there\u0026apos;s should be some opportunity for us to say hello to each other. (Care-Partner, F: #07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuggestion to improve social opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: N/A: not applicable or not available, F: female, M: male\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePre exercise themes (Themes 1-3):\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2.1 presents the themes that emerged as significant motivational factors influencing the participation of individuals with PD in exercise groups. Pre-exercise themes focus on motivators that encourage individuals to participate in the exercise program. Notably, nearly all (n=15). participants expressed motivation to engage in exercise programs. For some participants (n=5), their care partners played a crucial role in encouraging and supporting their exercise routines.\u003c/p\u003e\n\u003cp\u003eOne theme demonstrated that few individuals were directed to community resources for PD, such as the PAA, by their neurologist or physician (n=7), while many individuals independently discovered these resources (n=10). Additionally, two themes appeared, that were not directly related to the study\u0026apos;s objectives. One of them was delay in diagnosis of PD and associated challenges. Both individuals with PD (n=14) and their care partners expressed that the diagnostic process for PD is often lengthy and frustrating. This prolonged period can be emotionally challenging due to the uncertainty involved. Furthermore, the delay in diagnosis indirectly causes delays in treatment and disease management, including exercise interventions.\u003c/p\u003e\n\u003cp\u003eAnother theme was the challenges associated with living with PD. Within this theme, a prominent subtheme emerged\u0026mdash;a sense of loss. This subtheme was illustrated through unique narratives of participants (n=13) who described the loss of hobbies or aspects of their lifestyle. As PD causes a decline in fine motor and gross motor movements, many hobbies such as knitting, woodworking, and swimming may no longer be possible. This sense of loss can contribute to a decline in mood among individuals with PD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost exercise themes\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eTable 2. 2. highlights the post-exercise themes. The four themes identified encompass the benefits of exercise program participation, the motivational factors that promote long-term adherence, and the barriers and suggestions for improvements reported by both individuals with PD, care partners, and program-providers. A brief description of each theme is provided below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Improvement of symptoms:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Most participants with PD reported overall subjective improvement in mobility, strength, and endurance. Additionally, eight participants noted enhanced flexibility and reduced rigidity, while five participants observed better balance since joining the exercise program. Nine participants reported improved mood since joining the exercise program, while six participants noted increased confidence in their ability to walk and move and felt more hopeful about their mobility. Six participants reported overall improved pain since they joined the exercise program, while five of them perceived that participation in the exercise program may have played a role in slowing down the progression of the disease. Six care-partners reported that the program helped their partners to stay active and has enhanced their mobility confidence. One care-partner emphasized that the exercise increased strength. Some care-partners mentioned that participating in the exercise program uplifted their partner\u0026rsquo;s mood and had a positive effect on their quality of life. Program providers reported that they often observed a noticeable improvement in overall mobility of the individuals with PD after a few months of joining exercise program. Program providers also reported that they often receive feedback from participants that the program helped to bring a positive change in quality of life of individuals with PD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5: Benefits of exercise in groups:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFourteen participants with PD reported that group exercise provides mutual motivation to maintain physical activity. When exercises were challenging, emotional support from peers helped maintain self-esteem, fostering a supportive and encouraging environment. Participants highlighted that the sense of community from the group is crucial for their well-being. The exercise program\u0026apos;s community helped them discuss challenging issues, such as diverse symptoms and medication side effects. Many noted that this sense of community indirectly improved their mood and overall well-being. Participants expressed that they feel less self-conscious when exercising with individuals who have the same disease, compared to exercising with a non-PD population. This shared experience is an important motivating factor that sustains their ongoing participation in the exercise program. Five care partners noted that the exercise group motivated their partners, as it included others with similar disease severity, fostering mutual encouragement and shared learning. Five care-partners stated that individuals in the exercise group understand their partner\u0026rsquo;s health condition, making them happy that their partner is finally in a place where they can express their problems, feel heard and understood. Program providers also expressed that the community these individuals with PD have built play a vital role in terms of providing them support and motivation. Program providers mentioned that individuals with PD provide unwavering emotional support to each other.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 6: Motivating factors sustaining program attendance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifteen participants with PD (including both in-person and online classes) appreciated the instructor\u0026apos;s PD-specific knowledge and encouragement in fostering a supportive atmosphere. Thirteen participants valued the exercise program\u0026apos;s design in enhancing their health and quality of life. Five care partners noted its positive impact on their relationships and respite from responsibilities. Providers emphasized the program\u0026apos;s tailored services for different stages of PD, including education and exercise. Participants appreciated the PAA for providing PD-specific information, program management, and a supportive environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 7: Challenges in program participation and suggested improvements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants generally reported few challenges with program participation. However, seven participants with PD identified commuting as a significant barrier, often relying on partners due to their inability to drive. Although three participants noted that transportation is not currently an issue, they acknowledged it could become a challenge in the future possibly due to deteriorating health status. Both care partners and program providers identified transportation as a challenge, with care partners specifically reporting difficulties in transporting their partners, particularly during adverse weather. Nevertheless, they recognized the program\u0026apos;s importance and ensured attendance. Five participants identified the program\u0026apos;s cost as a financial challenge but deemed the benefits substantial enough to justify the expense, emphasizing the positive impact on their health. After learning that cost was a concern for participants, providers acknowledged it as a potential barrier to participation. To address the financial burden of out-of-pocket expenses, a few participants suggested tax deduction options, as the program is not covered by government funding.\u003c/p\u003e\n\u003cp\u003eParticipants made various suggestions, including some additional recommendations that did not emerge as main themes. Nine participants recommended enhancements to the PAA program, such as tracking symptoms to monitor disease progression, incorporating dance and music classes, providing access to diet consultants, organizing more social events, and including tailored cognitive exercises. Some of these existed previously but may have been trimmed down due to funding barriers. Care partners emphasized the necessity for additional support groups specific to care partners, both in-person and online, to foster mutual support among care partners. They also supported the addition of music and dance classes for individuals with PD and their care partners.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, people with PD perceived a PD-specific community-based exercise program as a positive experience, noting improvements in physical symptoms and psychological well-being. Seven themes, classified as pre-exercise and post-exercise, show program benefits, challenges, motivations, and perceived changes in quality of life. These themes provide valuable insights into the PD journey from the perspectives of individuals with PD, their care partners, and program providers.\u003c/p\u003e \u003cp\u003ePre-exercise themes primarily highlight the motivational factors that encouraged individuals with PD to join the exercise program. According to the COM-B model, motivation\u0026mdash;both automatic and reflective\u0026mdash;is essential for behaviour change [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our findings showed that participants were intrinsically motivated to exercise [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], demonstrating automatic motivation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While participants showed automatic motivation, care partners ongoing support contributed to reflective motivation. This combined motivation is crucial for long-term program adherence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, our study identifies that the extended period before diagnosis (a prerequisite for program enrollment) and the associated uncertainty often led to mental frustration for both individuals with PD and their care partners, aligning with previous research [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Within the COM-B model, this may indicate a lack of opportunity. The diverse symptoms of PD can disrupt hobbies and alter lifestyles, leading to a sense of loss. This, in turn, often contributes to a decline in mood which may already be part of the disease process - negatively impacting quality of life for individuals with PD [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe post-exercise themes in this study show that participants perceived several benefits from participating in a PD-specific community-based exercise program. Multicomponent programs incorporating aerobic, stretching, resistance, and cognitive exercises play an important role in improving quality of life, mobility, pain, and mood in individuals with PD [\u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. These programs also positively impact relationships between individuals with PD and their partners [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], an important, yet underemphasized aspect of PD. Adherence to the exercise program was influenced by the nature of the PD-specific exercises, supportive instructors, and the group setting [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Social interactions and community support provided by the PAA were crucial for enhancing mood and well-being [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. These factors provide both physical and social opportunities, supporting long term adherence, as indicated in the COM-B model. In our study, grouping individuals based on disease severity made them feel \u0026ldquo;less self-conscious\u0026rdquo; and more motivated to exercise with people at same level of functioning in line with the capability aspect of the COM-B model [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].This suggests that the perception of how people with PD engage in exercise may vary with disease severity [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], highlighting the psychological aspect of capability. Assessing the severity of the condition before group assignment may be essential for participation and long-term adherence to the exercise program. Notably, in PAA, pre-assignment screenings ensured appropriate group placements, which participants found satisfactory, underscoring the significance of physical capability.\u003c/p\u003e \u003cp\u003eOur findings demonstrate that the COM-B model provides a valuable framework for understanding the factors that support long-term adherence to community-based exercise programs for individuals with PD. Tailoring exercise programs based on disease severity emerged as a critical factor for engagement. Participants who underwent physiotherapist-led assessments were placed in appropriate groups, which enhanced both their physical and psychological confidence in exercising. This personalized approach may improve long-term adherence by ensuring that exercises are appropriately challenging yet manageable [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOpportunities for participation were influenced by both physical and social factors. Access to exercise equipment, knowledgeable instructors, and structured programs encouraged consistent engagement [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Group-based activities fostered social connections, which participants found highly motivating. However, logistical barriers such as transportation challenges, program costs, and limited awareness of available community resources may restrict participation, highlighting areas for improvement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Motivation played a central role, with participants demonstrating an inherent drive to stay active (automatic motivation). This was further reinforced by structured goal-setting, educational support, and encouragement from both care partners and exercise leaders (reflective motivation) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The combination of these motivational factors likely contributed to sustained participation and overall improvements in well-being [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. By addressing these elements\u0026mdash;ensuring appropriate exercise tailoring, improving accessibility, and fostering motivation\u0026mdash;community-based exercise programs can better support individuals with PD, enhancing both physical function and quality of life. Also, our study showed that PD-specific community-based programs can positively impact the relationships of individuals with PD and their partners, which may play a role in improving their mental health.\u003c/p\u003e \u003cp\u003eA limitation of this study is that only people who regularly attended the program were interviewed. Different perspectives may be captured by those who dropped out of the program or who were not interested in exercising. Factors such as lack of social support, worsening of PD-related symptoms, and lack of awareness of the role of exercise in PD have been previously documented as contributing to a lack of interest in exercise among individuals with PD [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study explored perspectives on a PD-specific community-based exercise program for individuals with PD, identifying benefits and barriers using the COM-B model. Both automatic and reflective motivation are essential for sustained participation. Assessing baseline capability and placing individuals in appropriate groups support long-term adherence. Participants reported that group exercise fosters a sense of community, while tailored programming enhances engagement in a community-based exercise program. However, barriers such as transportation, cost, and limited awareness of the benefits of exercise remain challenges. Addressing these factors through targeted education and accessible programming may optimize participation and long-term health outcomes in PD. Future research should examine the perspectives of people with PD and their care partners who do not participate in PD-specific community-based exercise programs to identify barrier to participation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e:\u0026nbsp;The University of Alberta\u0026apos;s Human Research Ethics Board approved this study (Ethics ID: Pro00122937). All participants provided written informed consent before enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: AK received Mitacs Accelerate studentship (# IT37143). The funding body had no role in the study\u0026apos;s design, collection, analysis, and interpretation of data, or in writing the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: All data generated or analysed during this study are included in this article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e: AK and VE conducted and analyzed the participant interviews. All authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDorsey ER, Bloem BR. The Parkinson Pandemic\u0026mdash;A Call to Action. JAMA Neurol. 2018;75:9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchiess N, Cataldi R, Okun MS, Fothergill-Misbah N, Dorsey ER, Bloem BR, et al. Six Action Steps to Address Global Disparities in Parkinson Disease. JAMA Neurol. 2022;79:929.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOu Z, Pan J, Tang S, Duan D, Yu D, Nong H et al. Global Trends in the Incidence, Prevalence, and Years Lived With Disability of Parkinson\u0026rsquo;s Disease in 204 Countries/Territories From 1990 to 2019. Front Public Health. 2021;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrighton EJ, Ou\u0026eacute;draogo AM, Sawada M, Mestre TA. 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Group-based exercise for Parkinson\u0026rsquo;s: a qualitative study of participants and partners\u0026rsquo; perceptions of an exercise class delivered through a community-university collaboration. BMC Geriatr. 2024;24:488.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleary AS, Rossi A, States RA. Parkinson\u0026rsquo;s Disease: Exploring Motives for Long-Term Adherence to a Group Exercise Program. Rehabilitation Nurs. 2020;45:131\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlynn A, Dennis S, Preston E, Canning CG, Allen NE. Exercising with Parkinson\u0026rsquo;s: The good, the bad and the need for support to keep exercising. A qualitative study. Clin Rehabil. 2022;36:1332\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams TL, Hunt ER, Papathomas A, Smith B. Exercise is medicine? Most of the time for most; but not always for all. 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Phys Ther. 2013;93:628\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Parkinson’s disease, Exercise, Phenomenology, Qualitative research, Behaviour change","lastPublishedDoi":"10.21203/rs.3.rs-6150621/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6150621/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParkinson\u0026rsquo;s disease (PD) is a progressive neurological disorder that significantly impacts individuals, their families, and the healthcare system. In addition to drug therapies and surgical interventions, exercise interventions have shown promise for improving both motor and non-motor symptoms in PD. This study aimed to investigate the perspectives of individuals with PD, care partners, and program providers about a community-based exercise program for PD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIndividuals with PD (Hoehn \u0026amp; Yahr stages I-III), on a stable medication regime, who had participated in a PD-specific community-based exercise program twice weekly for at least 12 weeks, along with their care partners and program providers were recruited to the study. Using a phenomenological qualitative study design, we conducted in-depth interviews with individuals with PD (n\u0026thinsp;=\u0026thinsp;17), their care partners (n\u0026thinsp;=\u0026thinsp;7), and program providers (n\u0026thinsp;=\u0026thinsp;3). The interviews, lasting 20\u0026ndash;50 minutes, were conducted from January 2024 to May 2024. Data were analyzed using interpretative phenomenology analysis framework, and findings were mapped onto a behaviour-change model. Two patient advisors and their care partners helped with data analysis and interpretation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e Participants consistently identified the PD-specific nature of the program and the benefits of exercising in a group as key motivators for participation. Pre-program challenges included difficulties obtaining a diagnosis, coping with the impacts of PD (such as a sense of loss, adapting to non-motor symptoms, and managing medication side effects), and finding motivation to exercise (self-motivation or encouragement from family/friends). Post-program outcomes included symptom improvement and positive experiences with group exercise, including mutual motivation, community support, and reduced self-consciousness. These positive experiences led participants to recommend increasing community awareness of the program. Identified barriers to participation included transportation difficulties and cost.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe PD-specific exercise program was perceived as beneficial to overall health and wellness, providing physical, emotional, and social benefits. A lack of awareness about the significance of exercise in PD remains a critical challenge, highlighting the need for clinicians to take a more active role in educating patients about the benefits of exercise, an area that appears underemphasized.\u003c/p\u003e","manuscriptTitle":"Community-based exercise programming for individuals with Parkinson’s disease: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-12 08:21:32","doi":"10.21203/rs.3.rs-6150621/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"697b7b90-4a5a-4127-80e5-59ac17c562ec","owner":[],"postedDate":"March 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-12T08:21:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-12 08:21:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6150621","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6150621","identity":"rs-6150621","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}