Exercise Snacks for People With Parkinson Disease: A Pilot Randomized Controlled Trial
Phase: NA
Conditions: Parkinson Disease
Sponsor: University of British Columbia

 
 
 
 
STUDY PROTOCOL 
 
Exercise snacks for people with Parkinson Disease: A pilot randomised controlled trial 
 
Short title: SNACK PD 
 
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Principal Investigator​ Daryl Wile, MD, MSc, FRCPC 
​
Clinical Associate Professor 
​
University of British Columbia Southern Medical Program​  
​
250-862-4181 
 
Co-Investigators ​
Jonathan Little, PhD 
​
School of Health and Exercise Sciences, University of British Columbia 
 
Study Personnel​
Mary Jung, PhD 
​
School of Health and Exercise Sciences, University of British Columbia 
​
Martin Gibala, PhD 
​
Faculty of Science, McMaster University 
​
Sean Dance, BKIN 
​
Community Kinesiologist, Research Consultant 
​
Roderick Sandilands, BKIN 
​
School of Health and Exercise Sciences, University of British Columbia 
​
Jill Williamson, PhD 
​
Clinical Research Coordinator, Centre for Chronic Disease Prevention and Management​
​
University of British Columbia 
 
Sponsor​
Parkinson Canada 
 
 
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Background & Scientific Justification​
3 
Objectives​
4 
Hypothesis​
4 
Method​
4 
Study Design​
4 
Study Population​
4 
Inclusion criteria​
4 
Exclusion criteria​
5 
Outcomes/endpoints​
5 
Baseline clinical data​
5 
Patient reported pre/post measures​
6 
Baseline clinical testing​
6 
End-of-study outcomes​
6 
Study Procedures​
7 
1. Recruitment and pre-intervention procedures​
7 
2. Study Onboarding Visit - Pre-randomization​
8 
3. Study Onboarding Visit - Randomization, Group Allocation​
8 
4.1 Study Period Overview​
9 
4.2 Seven Movements Platform​
9 
4.3. Exercise Snacks Group​
10 
4.4 Active Movement Breaks Group​
10 
4.5 Monitoring and post-intervention assessments​
11 
4.6 Actigraph LEAP device​
11 
Data Collection and Management​
12 
Statistical Analysis​
13 
Baseline Clinical Data​
13 
Patient-Reported Pre/Post Measures​
13 
Baseline clinical testing​
13 
End-Of-Study Outcomes​
13 
Ethical Considerations​
13 
Benefit and risk to participants​
13 
Reimbursement​
15 
References​
16 
Appendices​
19 
Appendix A - Exploratory survey response summary​
19 
Appendix B- Intervention Detail​
19 
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Background & Scientific Justification  
Many types of exercise benefit people with Parkinson’s Disease (PD) (Carvalho et al., 2015; Choi et al., 2020), 
contributing to the acceptance of exercise as an important element of treatment (Grimes et al., 2019). Despite 
this, many people with PD do not exercise, and their activity levels decline over time (Amara et al., 2019). 
Barriers to exercise include disease-related factors (motor disability, fatigue, apathy) as well as practical factors 
such as lack of time, facility/program access, weather, and financial burden (Ellis et al., 2013; Johnson et al., 
2018; Schootemeijer et al., 2020). 
 
People with PD need time-efficient, accessible exercise options that can be achievable by people with varied 
motor impairment, through different stages of their illness. Our proposal applies an innovative approach called 
“exercise snacks” or short bouts of vigorous effort that can be performed anywhere without specialized 
equipment or significant time commitment. This integrates exercise into daily life in a way that is flexible and 
achievable even for people who only briefly feel capable of exercising. 
 
Most aerobic exercise interventions studied in PD, including ‘high-intensity interval training,’ involve bouts of 
30-60 minutes of activity multiple times per week (Gilat et al., 2021; Schootemeijer et al., 2022; Ahmad et al., 
2023; Malczynska-Sims et al., 2022; van Wegen et al., 2020; Ernst et al., 2023). This presents a practical 
barrier to exercise, as sustained exercise may not be feasible for many people with PD. Short exercise bouts 
within daily life are seen by inactive adults as convenient and simple (Thøgersen-Ntoumani et al., 2023) and 
align with updated World Health Organization guidelines on physical activity and sedentary behavior (Bull et 
al., 2020) and the Canada 24-hour Movement Guideline for Adults' recommendation to break up long periods 
of sitting (Ross et al., 2020). Exercise snacks can significantly improve fitness, in a manner similar to traditional 
aerobic training and high-intensity interval training in other populations (Little et al., 2019; Jenkins et al., 2019; 
Islam et al., 2022). We hypothesize that they will also benefit people with PD. 
 
Exercise interventions must be accessible to benefit more people with PD. The majority of aerobic exercise 
interventions in PD exclude those with mild cognitive impairment or who need help walking or with daily 
activities (Ernst et al., 2023). Furthermore, most exercise interventions do not include a home component 
(Ernst et al., 2023). In the Canadian Community Health Survey, rural residents were more likely to report poor 
access to exercise facilities as barriers to physical activity (Pelletier et al., 2022). Since exercise snacks can be 
deployed to rural or remote environments within a participant’s home, we expect our intervention to be of 
particular benefit to our population in the Interior of British Columbia, where there is a much higher proportion 
of rural residents than the provincial average (CIHI, 2003). 
 
To develop the specific list of interventions presented in this study, we then undertook an iterative intervention 
design process. First, a series of one minute Exercise Snacks (28 options) and Active Movement Breaks (30 
options) were video recorded by Seven Movements and reviewed by Dr. Wile and Sean Dance for applicability 
to the study design, safety for the target population and refinement of the options. Further meetings were held 
to discuss the activity durations and variations to include, with a further series of two minute options video 
recorded by Seven Movements - as presented in this protocol.  
 
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We hypothesize that people with PD will see improvements in walking performance, fear of falling and quality 
of life in the Exercise Snacks group compared to the Active Movement Breaks group. 
 
Research Objectives & Hypothesis 
Objectives 
●​ Conduct a 12-week pilot randomized controlled trial of “Exercise Snacks” compared to a placebo 
exercise intervention (“Active Movement Breaks”) in people with PD. 
●​ Determine the proportion of people with PD eligible to participate, and rates of recruitment, adherence, 
and dropout. 
●​ Measure baseline and post-intervention patient reported and device obtained measures of active 
lifestyle, fear of falling, quality of life, and clinical measures of walking performance and balance in 
people with PD. 
●​ Evaluate barriers and facilitators for an Exercise Snacks intervention in PD, including qualitative 
enjoyment ratings and safety. 
●​ Estimate sample size for a future definitive RCT. 
Hypothesis 
Participants in the Exercise Snacks and Active Movement Break groups will be highly adherent to the 
prescribed activity. 
 
People with PD randomized to the Exercise Snacks group will see improvements in walking performance, fear 
of falling and quality of life when compared to the Active Movement Breaks group. 
Method 
Study Design 
An open-label, two-arm parallel-group, randomized pilot trial.  
Study Population 
We aim to recruit 40 adults with Clinically Established PD from Kelowna, BC from the Humphreys Family 
Movement Disorder Clinic. This study aims to be broadly inclusive, and the Exercise Snacks and Active 
Movement Breaks will be designed such that they can be safely performed by people within the target 
population, with direct observation and coaching through the study interventions (see onboarding session 
details below) before safely beginning the study period. 
 
Inclusion criteria 
 
●​ Adults (19 years of age or older) with Clinically Established PD (Postuma et al., 2015). 
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●​ Medically cleared to exercise by their physician. 
●​ A score of ≤3 on the modified Hoehn & Yahr scale (i.e. physically independent, may have unilateral or 
bilateral clinical signs, including mild impairment of postural reflexes). 
●​ Have access to a computer, tablet, or smartphone with internet connection for intervention delivery and 
tracking.  
 
Exclusion criteria 
 
●​ Comorbid condition with physical disability preventing participation in exercise (i.e., that cannot be 
accommodated with modifications to the prescribed exercise). 
●​ A score of >=4  on the modified Hoehn & Yahr scale (meaning they may be able to stand or walk but 
are not physically independent; this typically includes a need for gait aids such as a cane or walker) 
●​ No access to reliable internet connection. 
●​ Are currently participating in another clinical trial that would interfere with the study procedures 
described. 
●​ Have a scheduled event (e.g. medical or surgical procedure, prolonged travel in the next 3-4 months) 
that would interrupt participation in the study. 
 
Our study materials are presented in English. Participants who are not fluent in English will not be excluded 
and the research team will employ services to allow participation for non-native English speakers, including 
use of PHSA Interpreting services if needed, as recommended in the UBC Research Ethics Guidance on this 
matter.  
 
(https://researchethics.ubc.ca/sites/default/files/documents/Exclusion_of_research_participants_based_on_lan
guage.pdf). 
Outcomes/endpoints​
 
In addition to baseline clinical data, pre/post intervention outcomes will include patient reported measures, and 
walking and balance testing with a qualified study team member, and a five day window of actigraphy data 
from a wrist-worn device (Actigraph LEAP) prior to the study period. There will also be additional end-of-study 
outcomes.  
 
Baseline clinical data 
 
●​ Demographic information 
●​ Parkinson Disease characteristics and severity (symptom onset, diagnosis date, medication list and 
levodopa equivalent daily dose calculation) (Jost et al. 2023).  
●​ A recent (within 6 weeks) MDS-UPDRS III examination score (Goetz et al., 2008), including a modified 
Hoehn and Yahr scale score. 
 
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Patient reported pre/post measures 
 
●​ Canadian Society for Exercise Physiology (CSEP) Get Active Questionnaire (Screening questionnaire 
to safely participate in physical activity and exercise) (Canadian Society for Exercise Physiology 
[CSEP], 2017). 
●​ International Physical Activity Questionnaire - Short Form (IPAQ) - a measure of baseline physical 
activity (Craig et al., 2003). 
●​ Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE) (Jonasson et al., 2014, 
Nilsson et al., 2020, Kader et al., 2016), a measure of activity avoidance. 
●​ Parkinson Disease Quality of Life 39 item scale (PDQ-39) (Peto et al., 1998). 
 
Baseline clinical testing 
 
●​ Functional walking testing: two minute timed walk test (Bohannon et al 2015, Bowman et al., 2024), 
comfortable 10m walk test (Combs et al. 2014) and Timed Up and Go test (Dal Bello-Haas et al., 2011). 
●​ Berg Balance Scale (Berg et al., 1992). 
●​ Resting heart rate/blood pressure and post-exercise heart rate/blood pressure after a two minute 
example Exercise Snack (this is described in the study procedures below). 
 
End-of-study outcomes  
 
●​ Data from Seven Movements Platform 
○​ Adherence to the study intervention using activities logged in the Seven Movements platform. 
We will define these based on completion of target exercise: 
■​ Target: completion of at least 2 sessions five days per week, or 10 per week long block. 
■​ High (>70%), moderate (50-69%), or low (<50%) adherence. 
○​ Intensity of the exercise expecting a rate of perceived exertion (RPE) of >4/10 on the Borg 
CR-10 scale for Exercise Snacks, and greater RPE than the Active Movement Breaks group. 
○​ A summary of the Exercise Enjoyment Scale ratings of exercises to compare the study groups 
and assess for outliers / items requiring redesign or exclusion from future use. 
●​ Data from Actigraph LEAP device 
○​ Actigraphy data (segemented as sedentary time or mild/moderate/vigorous activity) from five 
day windows pre-study and post-study using actigraphy/accelerometer information from this 
device. 
○​ Heart rate data collected during two 5 day windows within the study period to assess the effect 
of Exercise Snack and active movement break interventions on heart rate. 
●​ Post Intervention Questionnaire 
○​ Acceptability of the intervention. 
○​ Barriers and facilitators to study activity. 
○​ Assessment of platform and technology in study. 
○​ Adverse events, safety concerns. 
●​ Path of recruitment and reasons for joining/not joining the study. 
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Study Procedures 
 
1. Recruitment and pre-intervention procedures 
 
Recruitment:  
Eligible patients are anticipated  to be seen by Dr. Wile at the Humphreys Family Movement Disorder Clinic.  
 
Recruitment workflow will be:  
1. Research personnel will be physically and readily available at the Humphreys Movement Disorder 
Clinic to continue the conversation about the study with potential participants (e.g., answer questions, 
complete informed consent) after their appointment with Dr. Wile.  
 
2. If the potential participant prefers, the study personnel will arrange a follow-up phone call to discuss 
the study 
 
3. If the potential participant prefers, they will be given the Study Card to link to the study for more 
information and the ability to reflect on their own time or discuss with their family without pressure. This 
study card includes contact information for the potential participant to connect with the study team if 
and when they are interested.  
  
 
Consent: 
Participants will be given as much time as they wish to review these materials and decide on participation. 
Participants will have the opportunity to contact study personnel to ask questions prior to committing to 
participate. 
 
Baseline clinical data: 
For participants who have had a clinical appointment with a neurologist within the previous six weeks, consent 
will be obtained to request those records from their treating clinician to abstract the baseline clinical data. If 
data cannot be obtained from existing clinical records, it will be obtained by Dr. Wile during the study 
onboarding visit. 
 
Patient reported measures: 
After informed consent, participants can complete pre-study questionnaires for baseline data using an 
additional survey tool link via Redcap.  These measures are listed in the patient reported measures section in 
the Outcomes/Endpoints section of this protocol.  
 
Pre-intervention review and scheduling: 
A study coordinator will review the data for completeness at that time and follow up with participants if there is 
missing data in the self-reported measures. The study onboarding visit will be scheduled. 
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2. Study Onboarding Visit - Pre-randomization 
 
After informed consent and completion of initial pre-study questionnaires, participants will be scheduled for a 
Study Onboarding Visit.  
 
At this visit: 
●​ Any missing baseline clinical data will be collected by Dr. Wile as listed in the outcomes/endpoints 
section. 
●​ Baseline clinical testing will be done with Roderick Sandilands as listed in the Outcomes/endpoints 
section. 
●​ Participants will review how to use the Seven Movements platform with a computer, smartphone, or 
tablet, including accessing instructional videos of their Exercise Snacks or Active Movement Breaks 
and how to complete post-activity records of their effort and enjoyment. 
●​ Participants will rate RPE for two activity examples (one each from the Active Movement Break and 
Exercise Snacks groups) with Roderick Sandilands prior to randomization. This will provide a way to 
show examples with different intensity to explain the RPE concept. 
●​ A baseline resting HR and BP will be collected before and following the Exercise Snack example 
intervention with Roderick Sandilands. 
 
3. Study Onboarding Visit - Randomization, Group Allocation 
 
●​ Participants will undergo randomization on the Redcap platform using a participant study ID code, sex, 
and Hoehn and Yahr scale score as inputs. A computer-generated randomization schedule with 
variable permuted block sizes will stratify blocks by self-reported biological sex (M/F) and Hoehn and 
Yahr scale score (1-2 or 2.5-3). 
●​ Participants will review the set of 12 Exercise Snacks or Active Movement Breaks they will perform 
during the study period with Roderick Sandilands, based on their group assignment. This review will 
serve as a safety check to ensure the individual participant can safely perform each of the assigned 
group Exercise Snacks or Active Movement Breaks, and allow an opportunity to review adaptations or 
modifications if any are needed. 
●​ A plan for incorporating exercise snacks or active movement breaks into participants’ daily routines with 
Roderick Sandilands will follow a standardized brief action planning interview guide.  
●​ The weekly schedule of Exercise Snacks or Active Movement Breaks will then be generated in two 
six-week blocks, and the simple, flexible structure described in the Study Period section below will be 
explained to participants. 
●​ Participants will receive the Actigraph LEAP device and review instructions on how to wear the device.  
●​ Participants will confirm their contact information, such that study personnel can conduct planned study 
contact phone check-ins; participants will be given contact instructions if they have technical questions, 
or study concerns.   
 
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While participants cannot be blinded in exercise interventions, specific study hypotheses will not be disclosed 
to participants; the study will be described as testing different types of “movement breaks” for improving fitness 
and mobility.  
 
4.1 Study Period Overview 
 
Both the Exercise Snacks and Active Movement Breaks groups will follow a similar schedule and structure for 
delivery of the study intervention, using the Seven Movements platform, and will provide the same structured 
feedback on their perceived effort and enjoyment.  
 
The study lasts 12 weeks and is divided into two 6-week phases. It begins the Monday after the Onboarding 
visit. Each week, two of the twelve available intervention options will be randomly chosen (without repeating 
any options) for participants to complete. By the end of the first 6 weeks, all twelve options will have been 
used. In the second 6-week phase, new random pairs of options will be assigned each week until the study 
ends. 
In both groups, the exercise sessions are flexible in timing and delivery. Participants can choose between the 
available options for each session and decide when to exercise based on when they feel able. This flexibility 
allows those with unpredictable treatment responses to pick the best time for them. The exercises are simple, 
require minimal preparation, and need no special equipment. 
Participants can achieve their activity targets on a weekly basis. They will be prescribed ten sessions in each 
7-day period, allowing for a rest day. They may elect to perform additional sessions if they wish.  
 
4.2 Seven Movements Platform 
 
The intervention will be conducted in partnership with Seven Movements, a company that specializes in the 
design and implementation of brief remote exercise interventions through technology, using a custom-built 
online and app-based exercise snacks platform.  
 
An example illustration of the user interface is shown in Appendix B. The Seven Movements platform provides 
participants with instructional videos showing safe and effective examples of the exercise options, provides 
reminders, and allows us to track exercise engagement, effort, safety, and enjoyment within the study. 
Notifications are provided as a reminder early in the day to be sure they remember to find time, and midday if 
they have not yet completed any sessions.  
 
Participants will be able to log the timing, duration, and number of sessions completed daily as well as the 
perceived effort (Borg CR-10 scale; Borg et al., 1982) and enjoyment (Exercise Enjoyment Scale; Stanley et 
al., 2009) into the platform.  
 
Participants will also be sent weekly self-report surveys via email RedCap link. If participants miss a weekly 
self-report survey, we will follow-up by email or telephone call to check in and address any concerns. Regular 
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phone check in sessions (10-15 minutes) will be held at weeks 4 and 8 to assess progress, adjust goals, and 
address any concerns. 
 
Participants will use anonymous, single-use accounts (e.g., “SNACK-PD-01”) with no identifying information 
stored. 
 
4.3. Exercise Snacks Group 
 
Participants will perform 2-minute Exercise Snacks, with ten sessions per week (typically 2 per day with 2 rest 
days), for a 12-week period. Exercises will consist of a mix of seated and standing actions, including 
body-weight exercises (e.g., squats, chair squats) and aerobic activities (e.g., stair marching in place, seated 
boxing), aimed at increasing heart rate while ensuring safety and ease of completion. 
 
Participants may adjust the intensity of the exercise through a weeklong period as they become familiar with 
the movements. Simpler and more advanced versions are presented in the videos, and where appropriate to 
the exercise some variations are presented that include simple changes like adjustments of the repetition rate, 
inclusion of vocal elements or use of a provided resistance band. Variations may also include performing 
movements e.g. with alternate arms vs. simultaneously with both arms.  
 
Participants can thereby tailor their sessions based on current abilities from the two exercise options and their 
variations. 
 
The specific activities for the Exercise Snacks group are: 
 
1.​ March in Place 
2.​ Chair Assisted Speed Squats 
3.​ Low Level Lateral Walk 
4.​ Squat then Side Lunge with Overhead Reach  
5.​ Overhead Axe Chop 
6.​ Wide Stance Lateral Duck Unders 
7.​ Chair Sit to Stand with Arm Horizontal Abduction 
8.​ Shadow Boxing Jab BH Combo 
9.​ Shadow Boxing Hook Combo 
10.​Shadow Boxing Uppercut Combo 
11.​Chair Sit to Stand to Box (alternating left-right) 
12.​1-2-1 Lateral Marching 
 
4.4 Active Movement Breaks Group 
 
Active Movement Breaks will mirror the format, schedule and delivery of Exercise Snacks. The Active 
Movement Breaks are designed to involve similar muscle groups / body regions compared to the Exercise 
Snacks interventions to mimic the engagement of the intervention group with less physical intensity. These 
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activities generally involve low-impact movements and stretches, with variations to accommodate participants' 
safety and preferences.  
 
1.​ Chair Assisted Calf Stretch 
2.​ Chair Assisted Long Hip Flexor Stretch  
3.​ Chair Assisted Abductor Stretch 
4.​ Chair Assisted lateral line Stretch 
5.​ Chair Assisted Hamstring Stretch 
6.​ Chair Assisted Wide Stance Rotation Stretch 
7.​ Chair Assisted Long Staggered Stance Lateral Hip Shift, Lateral Line OH Reach Mobilizer 
8.​ Wide Stance Rotation Hip Mobilizer 
9.​ Chair Assisted Single Leg Stance Hip Rotation 
10.​Chair Assisted Spine Extension Mobilizer 
11.​Chair Assisted T Spine Rotation Mobillizer 
12.​Forward Step Shoulder and Spine Extension Mobilizer 
 
 
4.5 Monitoring and post-intervention assessments 
 
Check in calls from a study coordinator will occur on the Tuesday (day 2) of weeks 1 and 2. These will be 
designed to address any early logistical issues with the study procedures, Seven Movements platform, or 
exercises. 
 
A scheduling call will occur during week 10 to schedule a study end visit within 2 weeks of study completion.  
 
Interim safety review calls will occur on the Tuesday of weeks 4 and 8.  During these calls, a structured 
discussion of the individual exercises completed to date will occur and responses will be stored in Redcap 
including: 
●​ Subjective comments about difficulty, environment needs or limitations of certain exercise options. 
●​ Reasons for preferring one option over another during a weekly block. 
●​ Safety concerns or injuries. 
●​ Technical challenges with the delivery platform or study contact. 
●​ Barriers to completing prescribed amounts of exercise sessions. 
 
A final study review will occur including the same elements for weeks 9-12 during the study end visit. 
 
The study end visit will also include a study specific acceptability questionnaire that will include open-ended 
questions to help us explore the barriers and facilitators to exercise completion, and rating which elements of 
the intervention are most effective for participants. 
 
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4.6 Actigraph LEAP device 
 
Participants will review the Actigraph wearable device at the baseline assessment, ensuring they understand 
how to use and charge the device.  The device will be fully programmed for the participant prior to use. Specific 
instruction and support will include: 
●​ How to wear the device correctly. 
●​ How to charge the device (expecting that this will be required only after roughly 5 days of use). 
●​ Participants will be provided with a compatible charger. 
●​ Participants will be asked to wear the device continuously for 5 days prior to starting the intervention, 
while conducting routine daily activities as usual. 
●​ Participants will again wear the device continuously for the first 5 days of the study period.  
●​ Participants can return the device after this data collection period, and continue the remainder of the 
study period without the device. This can be done in person if convenient for the participant, or using a 
provided pre-paid shipping envelope (i.e., at no cost to the participant). 
●​ At week 10 of the intervention period the Actigraph device and charger will be provided back to the 
participant by the research team either in person or by mail.  Participants will be asked to wear the 
device continuously for the final 5 days of the study period and additionally for 5 days after the end of 
the study period.   
●​ Participants can remove the device at any time (a) if they find the device uncomfortable to wear, even if 
they wish for a break of a few hours or overnight (b) if they wish to remove the device for certain 
activities during the collection periods (c) if they wish to charge the device. 
 
Of note, participants are not required to use any associated software (Actilife) or interact with the device during 
the wearing period, as all data collection occurs in the background. The device display shows the current time, 
and the device does not transmit stored data wirelessly in this study (Bluetooth connectivity is disabled), does 
track participants’ location, or contain any personal identifying information. For more details, the device manual 
is available to participants in full (Actigraph LEAP Device Manual.pdf).  
Data Collection and Management 
Study data platform 
 
Redcap will be the primary data gathering and management platform for this study. Redcap is provided by UBC 
Advanced Research Computing (ARC) for data capture in accordance with data privacy and storage described 
herein: https://arc.ubc.ca/security-privacy/arc-redcap-security-and-privacy 
 
Specifically The ARC REDCap platform meets the requirements of UBC Information Security Policy SC14 and 
associated Standards, and has undergone a Privacy Impact Assessment (PIA01956). The platform is equipped 
with multiple security controls:  
 
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●​ The platform runs on server infrastructure physically located in BC, Canada, at the UBC University Data 
Centre (UDC). 
●​ The platform is integrated with Enhanced UBC CWL Campus-Wide login, with 2-factor authentication 
for users. 
●​ The platform can be configured by researchers to separate data logically and allow complete 
separation of Sensitive and Personal Information from de-identified research data within a single 
project.   
●​ ARC has a Security Incident Response protocol in place to ensure security and privacy incidents are 
mitigated in a timely manner. 
●​ The ARC REDCap platform and underlying infrastructure are periodically scanned for security 
vulnerabilities, and patched per the requirements of UBC Information Security Standard M5 
●​ Data stored in the ARC REDCap platform is encrypted. 
●​ The platform is fully supported and maintained by UBC Advanced Research Computing. 
 
Clinical, survey and in person assessments 
 
Baseline clinical data will be captured from the review of participant clinical records or newly obtained at the 
baseline visit, and input into Redcap. 
 
Patient reported pre/post measures will be collected by Redcap survey link and directly stored within the study 
database. 
 
Baseline clinical testing outcomes will be directly collected into a Redcap webform at the time of capture. 
 
Seven Movements 
 
Seven Movements exercise completion, RPE and Exercise Enjoyment Scale data, as well as the timing of 
session completions, will be stored in the Seven Movements platform until study completion, and then imported 
into the Redcap study database after data collection is complete.  
The Seven Movements platform follows GDPR (General Data Protection Regulation) and other data protection 
laws to ensure privacy. Data storage is done using Google Firebase on secure servers in the US.  Data is 
encrypted in transit and at rest, with strict access controls and continuous monitoring for security. 
Actigraph LEAP 
The ActiGraph LEAP devices record movement patterns and heart rate during the wearing periods. The 
research team pre-configures the devices to disable bluetooth wireless connectivity. 
 
To ensure participant privacy from the outset, ActiLife allows the use of de-identified codes instead of 
personally identifiable information (PII), reducing the risk of data linkage to specific individuals. 
 
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Once collected, data is downloaded in proprietary file formats such as *.agd or *.gt3x, which store raw 
accelerometer readings. These files will be downloaded by USB connection to a UBC CWL 
password-protected and encrypted study laptop.  Access to raw data will be restricted to authorized personnel 
only (i.e., those authorized in REB), with clear protocols in place for data sharing and transfer.  Collecting only 
the information essential for study objectives, the study team will also ensure all identifiable data is stored 
separately from analysis datasets.  Before data collection, participants will be informed about what data will be 
recorded, how it will be stored, who will have access, and the measures in place to protect confidentiality. This 
will be done at both the Informed Consent Form step and again at the Baseline Assessment.  
 
Statistical Analysis 
Baseline Clinical Data 
For baseline clinical data, descriptive statistics will be used to characterize the study population. Parkinson's 
disease characteristics such as symptom onset, diagnosis date will be summarized for group equivalence 
along with our stratification variables (sex and Hoehn and Yahr scale). Continuous variables like symptom 
duration and levodopa equivalent daily dose (LEDD) will be reported as means and standard deviations (or 
medians and interquartile ranges if non-normally distributed). Categorical variables such as the more affected 
side will be summarized using frequencies and percentages. MDS-UPDRS III scores and modified Hoehn and 
Yahr scores will be analyzed using means and standard deviations. Additionally, resting and post-exercise 
heart rate and blood pressure data will be compared pre- and post-exercise using unpaired t-tests or Wilcoxon 
signed-rank tests to assess the cardiovascular response to the Exercise Snack example. 
 
Patient-Reported Pre/Post Measures 
Linear mixed models will be used with group and time (and their interaction) as fixed effects and participant ID 
as a random effect. Stratification factors will be included in the model as fixed effects and to explore their 
interaction on outcomes. The between group effect estimate with 95% confidence interval will be the main 
outcome of interest. Within-group changes over time will also be reported as effect estimates from the model 
with 95% confidence intervals.   
 
Baseline clinical testing 
Similarly we will use a linear mixed model to analyze baseline clinical testing data.  
 
End-Of-Study Outcomes 
Adherence will be categorized into high, moderate, and low adherence, based on the percentage of completed 
exercise snacks. The relationship between adherence and outcomes will be explored where appropriate using 
correlations or linear regression. Rate of perceived exertion (RPE) and Exercise Enjoyment scores will be 
summarized and evaluated to ensure participants reached the targeted exercise intensity in the Exercise 
Snacks group and to compare intensity and enjoyment with the Active Movement Breaks group. 
 
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Data from the end-of-study questionnaire assessing intervention acceptability will be summarized using 
descriptive statistics with open-ended responses used to help identify barriers, facilitators, and safety concerns 
related to the intervention. 
 
Recruitment path and reasons for joining or not joining the study will be summarized using descriptive 
statistics. 
Ethical Considerations 
Benefit and risk to participants 
 
Risks to participants are mitigated in this self-administered exercise intervention clinical trial by initial inclusion 
safety and activity assessments including those recognized by CSEP as determinants of readiness to exercise. 
We have designed the study elements in consultation with exercise professionals experienced in working with 
people with PD (Sean Dance) and offer options and variations of exercise to accommodate unpredictable or 
fluctuating ability. We allow participants to determine the time they feel safest and most capable to complete 
the session during their day.  
 
The risks associated with the exercise protocols completed for this study are the same as the physical 
discomfort or strain during exercise performed in daily life including fatigue, fainting, and/or muscle soreness. 
When feasible, participants will be encouraged to have a support individual present when engaging in activities 
to minimize any related risk and/or assist in the event help is required.   
 
Furthermore, participation is at-will and participants can stop at any time without any consequence (as 
explained in the consent form). Participants will be asked to perform activities in a manner that they control, 
thus further minimizing their risk. This study does not pose any risks greater than what they may normally 
encounter when using a similar exercise intervention strategy.  
 
Dr. Wile has a potential dual role conflict of interest for participants. Dr. Wile is therefore involved with 
screening for eligibility at the point of clinical care, but research personnel will conduct any further discussions 
about the study, enrollment or review of consent documents. 
 
It is foreseeable that during these study procedures, clinical issues or questions may arise from participants 
that may require further clinical review or attention. In these cases, Dr. Wile will separately schedule and 
document a clinical encounter regarding that issue through the Humphreys Family Movement Disorder Clinic at 
KGH. This will include standard clinical documentation to the primary care physician. In the case of patients 
who already have an established clinical relationship, this will be conducted through the existing clinic chart. 
For patients with whom there is no current established relationship, a letter to the primary care physician will be 
written to describe the clinical concerns, and options for next steps will be suggested. 
 
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There is no guarantee of benefit to people participating in the study, however the study has the potential to 
benefit people with PD who are: 
 
●​ Unable to complete prolonged bouts of exercise. 
●​ Struggling with variable / unpredictable physical ability and motivation to exercise during the day. 
●​ Living in rural, under-served and resource-poor areas where practical barriers to exercise are more 
likely to exist. 
 
Participants will receive a plain language summary of the results and they will have the option to ask questions. 
Reimbursement 
Any costs that participants could incur associated with parking for visiting UBC Okanagan will be covered by 
the study.  If there are any unexpected receipts related to costs of the study, participants will be asked to retain 
them and provide them to the research team at the end of the study period to receive reimbursement. 
 
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correlates of physical activity in Canadian adults. Prev Med Rep. 2022 Dec;30:102061. 
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Appendices 
Appendix A - Exploratory survey response summary  
Our exercise platform partner Seven Movements has an established relationship with the Michael J Fox 
Foundation for Parkinson’s Research. Seven Movements approached this organization and conducted two 
focus groups. A positive response from participants led to development of a survey distributed to participants in 
the MJFF Parkinson’s Buddy Network (https://parkinsonsbuddynetwork.michaeljfox.org/v2/). When discussing 
this pilot project we invited people from our Kelowna PD support group to participate in the survey. Though we 
did not collect identifying information or geographic data from respondents, we infer from the timing of 
responses that 16-20 respondents are from our local population, and 112-116 (total 132 respondents) are from 
the MJFF Buddy Network. Responses included information about the respondent’s demographics, diagnosis of 
PD and duration, their exercise habits, exercises they find helpful and enjoyable, barriers to exercise and 
attitudes about brief exercise interventions and technology-based exercise programs.  
 
132 responses were collected from October 11, 2023 to November 21, 2023. Though we expect responses 
were affected by selection bias, we note nearly 40% of our sample were diagnosed more than 5 years prior to 
response, and nearly half were over age 70. 64 Respondents were female (48.5%). 58 responses (43.9%) 
were from people age 70 or older. 39 had been diagnosed with PD in the past two years (29.5%) 42 between 
2-5 years (31.8%) and 51 more than 5 years (38.6%). 29 respondents (22%) reported not regularly 
participating in exercise, and 103 reported regular exercise habits. Non-exercisers were more commonly over 
age 70 (14/29; 48.3%) and with more than 5 years since diagnosis (16/29; 55.2%) or 2-5 years (8/29; 27.6%).  
Both exercisers and non-exercisers reported barriers to regularly exercising. From open ended responses we 
identified common response themes including motor symptoms (e.g. stiffness, dystonia, unsteadiness, 
imbalance; 41), practical issues (time and travel required, facility access, fluctuations and unpredictable 
function; 38) nonmotor symptoms (e.g. amotivation/apathy, fatigue, sleepiness; 37), comorbidities limiting 
activity (arthritis or other causes of pain;13) and safety concerns (e.g. fall risk; 10).  
 
Exercisers employed a variety of exercise types which we classified as aerobic exercise (132), balance training 
(70), flexibility (61), strength / resistance (56), and 71 other responses including group activities and exercise 
as part of activities of daily life. Common responses within these groups were used to develop example 
exercise snacks (aerobic, some strength/resistance options) or movement breaks (flexibility). Examples are 
shown in Appendix B. 
Though we expect responses were affected by selection bias, 82% of respondents had discussed exercise 
with their healthcare provider as part of their treatment. 93% endorsed interest in using a platform to guide 
them brief exercise techniques and 86% would consider participating in a pilot study of such a system. 
 
Appendix B- Intervention Detail  
The Seven Movements platform will be reviewed with participants during initial onboarding and participants can 
tailor and customize a schedule of reminders for movements. Note: We will combine our clinical expertise in 
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PD (Wile) with exercise snacks physiology (Little and Gibala) and Seven Movements surveys of pwPD to 
develop accessible standing and seated exercise snacks that are appropriate yet challenging for pwPD. 
 
Instructional videos are available in the app alongside movement options:  
 
Examples include an Exercise Snack (march in place) and Active Movement Break (teapot).  
 
Participants will log the daily exercise snacks completed, their perceived effort (Borg CR-10 scale), and 
enjoyment (Exercise Enjoyment Scale) in the platform: 
 
 
 
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