# All's well that ends well: an early-phase study testing lower end-session exercise intensity to promote physical activity in patients with Parkinson's disease

Layan Fessler, Philippe Sarrazin, Silvio Maltagliati, Annique Smeding, Boris Cheval

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## To cite this version:

Layan Fessler, Philippe Sarrazin, Silvio Maltagliati, Annique Smeding, Boris Cheval. All's well that ends well: an early-phase study testing lower end-session exercise intensity to promote physical activity in patients with Parkinson's disease. Movement & Sport Sciences - Science & Motricité, 2024, 123, pp.17-31. 10.1051/sm/2023009. hal-04892447

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Submitted on 14 Jun 2025

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ARTICLE

# All's well that ends well: an early-phase study testing lower end-session exercise intensity to promote physical activity in patients with Parkinson's disease

Layan Fessler<fnref n="1" />,*, Philippe Sarrazin<fnref n="1" />, Silvio Maltagliati<fnref n="1" />, Annique Smeding<fnref n="2" />, and Boris Cheval<fnref n="3" />,<fnref n="4" />

Received 30 November 2022, Accepted 17 April 2023

**Abstract** - Decreasing the intensity of exercise at the end of a session has been associated with greater post-exercise pleasure and enjoyment. Here, we investigated whether this manipulation can enhance affective attitudes toward physical activity (PA) and promote PA in patients with Parkinson's disease (PD). Seven patients (72.9 ± 5.6 years, 3 women) were included in an eight-week within-subject study consisting of weekly exercise sessions. The first four weeks were used as a control condition. In the last four weeks, 9 minutes of lower-intensity exercise were added at the end of each session (experimental condition). Results of the linear mixed-effects models showed that the addition of lower-intensity exercise improved the explicit affective attitudes toward PA (b = 1.00, 95%CI = 0.36 to 1.64, P = 0.022). We found no evidence of an effect on implicit affective attitudes (P = 0.564), accelerometer-based PA (P = 0.417) and self-reported measures of PA (P = 0.122). Although not significant, self-reported PA per day was 36 minutes longer in the experimental than in the control condition. The findings of this early-phase study may suggest that reducing the intensity of an exercise at the end of the exercise sessions enhanced explicit affective attitudes toward PA in patients with PD. Yet, future well-powered and randomized studies are needed to provide more robust evidence.

**Keywords:** Parkinson's disease, physical activity, effort, affects, peak-end rule

**Résumé** - Tout est bien qui finit bien : une étude préliminaire testant l'efficacité d'une baisse d'intensité en fin de séance d'exercice pour promouvoir l'activité physique chez des patients atteints de la maladie de Parkinson. La diminution de l'intensité de l'exercice à la fin d'une séance a été associée à un plus grand plaisir après l'exercice. Ici, nous avons cherché à savoir si cette manipulation pouvait améliorer les attitudes affectives à l'égard de l'activité physique (AP) et promouvoir l'AP chez les patients atteints de la maladie de Parkinson. Sept patients (72,9 ± 5,6 ans, 3 femmes) ont été inclus dans une étude intra-sujet de huit semaines comprenant des séances d'exercice hebdomadaires. Les quatre premières semaines ont été utilisées comme condition de contrôle. Au cours des quatre dernières semaines, dix minutes d'exercices de moindre intensité ont été ajoutées à la fin de chaque séance (condition expérimentale). Les résultats des modèles linéaires à effets mixtes ont montré que l'ajout d'exercices de faible intensité a amélioré les attitudes affectives explicites à l'égard de l'AP (b = 1,00, 95 % IC = 0,36 à 1,64, p = 0,022). Nous n'avons trouvé aucune preuve d'un effet sur les attitudes affectives implicites (p = 0,564), l'AP basée sur des accéléromètres (p = 0,417) et sur les mesures d'AP autodéclarées (p = 0,122). Bien que cela ne soit pas significatif, l'AP journalière autodéclarée était supérieure de 36 minutes dans la condition expérimentale par rapport à la condition contrôle. Les résultats de cette étude préliminaire peuvent suggérer que la réduction de l'intensité d'un exercice à la fin des séances d'exercice améliore les attitudes affectives explicites à l'égard de l'AP chez les patients atteints de la maladie de Parkinson. Cependant, de futures études randomisées et de puissance suffisante sont nécessaires pour fournir des preuves plus solides.

**Mots clés** : maladie de Parkinson, activité physique, effort, affects, règle du pic et de la fin

<footnote n="1">¹ Univ. Grenoble Alpes, SENS, 38000 Grenoble, France</footnote>

<footnote n="2">² Univ. Savoie Mont Blanc, Univ. Grenoble Alpes, LIPPC2S, 73000 Chambéry, France</footnote>

<footnote n="3">³ Swiss Center for Affective Sciences, University of Geneva, Geneva, Switzerland</footnote>

<footnote n="4">⁴ Laboratory for the Study of Emotion Elicitation and Expression (E3Lab), Department of Psychology, University of Geneva, Geneva, Switzerland</footnote>

<footnote>* Corresponding author: Université Grenoble-Alpes, 621, avenue Centrale, 38400 Saint-Martin-d'Hères, France.
layan.fessler@univ-grenoble-alpes.fr.</footnote>
# 1. Introduction

Parkinson disease (PD) is the second most common neurogenerative disorder worldwide affecting 2–3% of the population aged 65 years or older (Connolly & Lang, 2014; Poewe et al., 2017). This chronic disorder is characterized by motor and non-motor symptoms including tremor, rigidity, slowness of movement, cognitive impairment, mood and affective disorders, as well as depressive symptoms (Chaudhuri, Healy, & Schapira, 2006: Obeso et al., 2017). Accumulating evidence suggests that patients with PD can benefit from physical activity (PA) (Chen, Zhang, Schwarzschild, Hernan, & Ascherio, 2005: Speelman et al., 2011). For example, PA can improve motor performance (Goodwin, Richards, Taylor, Taylor, & Campbell, 2008), cognitive function (Murray, Sacheli, Eng, & Stoessl, 2014), quality of life (van Uem et al., 2018), and depressive symptoms (van Uem et al., 2018). Despite such benefits, many patients with PD do not engage in the recommended levels of PA and are typically less active that the general population (Cavanaugh et al., 2015; Pradhan & Kelly, 2019). Developing interventions promoting PA in this population is thus warranted.

## 1.1. The theory of effort minimization in PA

Interventions promoting PA in patients with PD are mostly grounded in the dominant socio-cognitive theories (Ellis & Motl, 2013; Krishnamurthi, Fleury, Belyea, Shill, & Abbas, 2020: Speelman, van Nimwegen, Bloem, & Munneke, 2014: van Nimwegen et al., 2013). In short, these theories focus on the reflective precursors of action and argue that changing people's conscious cognitions (e.g., attitudes, intention, self-efficacy, goals) should lead to substantial change in their behaviors (Ajzen, 1991; Bandura, 1997; Prochaska & DiClemente, 1982: Sheeran, Gollwitzer, & Bargh, 2013). Although these interventions have proven to be effective to change PA behavior to some extent (Gourlan et al., 2016), meta-analyses also indicate that these interventions are more effective in changing intentions than actual behavior (Rhodes, Boudreau, Josefsson, & Ivarsson, 2021). Likewise, automatic processes have recently gained traction to shed lights on this intention-behavior gap (Brand & Ekkekakis, 2018; Cheval & Boisgontier, 2021; Conroy & Berry, 2017; Larsen & Hollands, 2022). Notably, an automatic attraction toward effort minimization has recently been proposed to account for the difficulties of the dominant socio-cognitive
theories to explain failures in turning intentions to be physically active into behavior (Cheval & Boisgontier, 2021).

Based on a neuropsychological approach to physical effort (Bernacer et al., 2019; Klein-Flügge, Kennerley, Friston, & Bestmann, 2016) anchored in an evolutionary perspective (Cheval, Radel et al., 2018; Lieberman, 2015), the Theory of Effort Minimization in PA (TEMPA; Cheval & Boisgontier, 2021) argues that humans have evolved an automatic attraction toward physical effort minimization, which restrains the engagement in PA. In line with TEMPA, findings of previous research suggested that avoiding stimuli related to effort minimization requires higher inhibitory control than approaching these stimuli (Cheval et al., 2021; Cheval et al., 2020; Cheval, Tipura et al., 2018). Other results showed that the ability to overcome the automatic attraction to effort minimization is essential to the engagement in PA (Bernacer et al., 2019; Cheval, Sarrazin, Isoard-Gautheur, Radel, & Friese, 2015; Cheval, Tipura et al., 2018).

In line with the dual-process models of PA (Brand & Ekkekakis, 2018; Cheval, Radel et al., 2018; Conroy & Berry, 2017), TEMPA argues that the affective evaluation of PA is instrumental to the regulation of this behavior. Specifically, positive affective evaluations (e.g., pleasure) experienced during PA are believed to favor initiation and continuation of PA behavior. Conversely, negative affective evaluations (e.g., displeasure) experienced during PA are believed to hinder initiation and continuation of PA behaviors. In line with these theories, studies showed that affective responses to exercise predict future engagement in PA (Rhodes, McEwan, & Rebar, 2019; Williams & Bohlen, 2019).

According to TEMPA, the lack of engagement in PA results from an inability to overcome the perception of physical effort, an inability that might be particularly pronounced among patients with PD. For example, behavioral apathy, which is often observed in patients with PD, may reflect an inability to accurately perceive physical effort or an altered sensitivity to this effort (Bonnelle, Manohar, Behrens, & Husain, 2016). TEMPA posits that the affective value of PA moderates the perception of effort. Higher positive affective evaluations may reduce the perception of effort associated to a given behavior and, in turn, favor the initiation and continuation of PA behavior. In sum, developing positive affective evaluation of PA through the reduction of the perception of effort may promote PA (Cheval & Boisgontier, 2021).
1.2. The peak-end rule in exercise

Interventions that manipulate the affective evaluation of exercise to promote PA are rare (Conroy
& Kim, 2020; Williams, Rhodes, & Conner, 2019), but recent studies have developed such interventions
drawing on the peak- end rule (Hargreaves & Stych, 2013; Hutchinson, Zenko, Santich, & Dalton, 2020;
Zenko, Ekkekakis, & Ariely, 2016). This rule is based on two mechanisms underlying the affective evaluation
of PA. The first mechanism refers to the link between effort intensity and affective evaluation. Higher
intensity PA (i.e., above the ventilatory threshold) reduces pleasure and increases displeasure (Ekkekakis,
Parfitt, & Petruzzello, 2011). The second mechanism postulates that the global evaluation of an experience
mainly depends on the affects experienced during the most intense affective moment of the experience
(i.e., « peak ») and at the end of the experience (i.e., « end ») (Fredrickson, 2000; Kahneman, Fredrickson,
Schreiber, & Redelmeier, 1993). Combining these two mechanisms, studies have investigated how the
dynamic of effort intensity during an exercise session impacts the global affective evaluation of the session.
The hypothesis is that lower effort intensity at the end of the session results in a more positive affective
remembered experience, which favors a more positive global affective evaluation of PA (i.e., generalization
of a specific experience to PA in general).

To the best of our knowledge, only four studies have directly manipulated the dynamics of effort
intensity during exercise (Brewer, Manos, McDevitt, Cornelius, & Van Raalte, 2000; Hutchinson et al., 2023;
Hutchinson et al., 2020; Zenko et al., 2016). In their study, Zenko et al. (2016) randomly assigned 46 healthy
adults into a 15-min exercise session on a recumbent bike either in an increasing or decreasing-intensity
condition. Results showed that the decreasing-intensity condition was associated with greater post-
exercise pleasure, enjoyment, remembered pleasure (i.e., affective memories of the session), and
forecasted pleasure (i.e., anticipation of the affect in a future session). Using a single session or six
repeated sessions of resistance training circuit, Hutchinson et al. (2020, 2023) observed similar effects on
the remembered and forecasted pleasure, but not on the explicit and implicit affective attitudes toward
PA. Finally, Brewer et al. (2000) showed that adding a 5-min period of reduced exertion at the end of a 15-
min stationary bicycle session was perceived as less aversive than a 15-minute session alone. In sum, these
studies showed that manipulating the dynamic of effort intensity influences the affective evaluation of an exercise session, but evidence that this manipulation can generalize to the global affective evaluation of PA is lacking. Likewise, whether the manipulation of effort can impact subsequent PA behavior remains unknown.

The aim of the present study was to assess whether manipulating the intensity of effort at the end of exercise sessions enhances affective evaluation of PA and promotes daily-life PA behaviors in patients with PD. Based on TEMPA (Cheval & Boisgontier, 2021) and on the peak-end rule (Fredrickson, 2000; Kahneman et al., 1993), we hypothesized that a weekly session for 4 weeks ending with a 9-min bout of light-intensity exercise would result in more positive explicit and implicit affective evaluations of PA compared with a weekly session for 4 weeks without the final 9-min bout (*H*₁). We also hypothesized that self-reported and accelerometer-based daily-life PA would be higher during the four weeks with than without the final 9-min light-intensity bout (*H*₂).

## 2. Materials and methods

Study preregistration, material, and data can be found at https://zenodo.org/record/4742001#.ZAr-FsGZMQM and https://aspredicted.org/see_one.php.

### 2.1. Deviation from the ethics protocol

In the ethics protocol, we stated that we would use a randomized controlled trial, including an experimental and a control group using a between-subject design. Because of difficulties in patients' recruitment, we changed this strategy to leverage the benefits of a within-subjects design. Specifically, each patient per-formed both the control and experimental conditions in a fixed order. Likewise, we wrote that we would follow the patients the week after the intervention. This follow-up was not performed because of time and resources constraints. We also stated that we would measure the approach-avoidance tendencies toward PA as well as the affective responses, perceived effort, and heart rate during each exercise session. These measures were not implemented because of time and resources constraints. All these modifications relative to the ethics protocol were indicated in the pre-registration.
## 2.2. Participants

Participants were recruited through the exercise program of a Swiss private clinic in January 2021. To be included in the study, participants should be 18 years of age or older and clinically diagnosed with PD. Participants were excluded if they had contraindications to PA, dementia (Mini-Mental State Examination Score 24; (Folstein, Folstein, & McHugh, 1975) or motor dependence (stage 5 on the Hoehn and Yahr Scale; (Hoehn & Yahr, 1998). All these inclusion and exclusion criteria were checked by the medical staff using patients' clinical records. Given the small number of patients in the department, we initially aimed to recruit as many patients as possible (i.e., n = 20) (Fig. 1). As such, the sample size was limited by resources constraints (Lakens, 2022). The study was approved by the French National Ethics Committee for Research in STAPS (reference number: IRB00012476-2022-08-03-159). All participants signed an informed consent form to participate in the study.

## 2.3. Procedure

In a within-subjects design, participants were first invited to a clinical visit to provide written informed consent and filled in a self-reported questionnaire about their age, sex, height, and weight, motivation toward PA (i.e., intention, attitudes, and self-efficacy), and usual PA. They also performed a task measuring implicit affective attitudes toward PA (Rebar, Ram, & Conroy, 2015). Participants then completed a four-week exercise program (i.e., control condition) and four additional weeks in which a ten-min exercise bout of light intensity was added (i.e., experimental condition). Exercise sessions were performed once a week for both conditions. The intervention was delivered in the exercise room of the La Lignère Clinic, Switzerland, by the physiotherapists. Implicit and explicit affective attitudes were assessed at baseline, at the end of the control condition, and at the end of the experimental condition. Self-reported and accelerometer-based measures of PA were performed on a daily-basis across the eight weeks.
<caption>**Figure 1**</caption>

*Flow chart*

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## 2.4. Exercise sessions

Each exercise session started with a 15-min warm-up period including light-intensity exercises mobilizing articulations, cardiovascular and muscular systems, gait, and balance. Then, three 9-min bouts of circuit training were performed (see Tab. S1 for more details). Each round was composed of six 1-min bouts of exercise followed by a 30-sec rest period. The circuit included muscle, cardiovascular and balance work at a moderate intensity. In order to ensure the intended exercise intensity for each condition, participants were asked to estimate their perceived effort twice during each 9-min bout using a modified version of the CR10 Scale (Kern & Fautrelle, 2018). Specifically, following the question “What level of effort do you perceive at this very moment?”, patients were asked to maintain an effort that matches a rating between a moderate (i.e., 3 on the 10-point scale) and strong (i.e., 5 on the 10-point scale) intensity using the following instruction “Please maintain an effort between 3 (moderate) and 5 (strong). Three refers to an increase in breathing but with the ability to hold a conversation; five refers to a heavier breathing and
it becomes difficult to hold a conversation." The last 4weeks of the 8-weeks program, a 9-min exercise bout was added. In this fourth 9-min bout, participants were asked to perform the exercises at an intensity between 1 (very weak; "almost no effort but more difficult than standing still") and 2 (weak; "feels like you can hold it for hours") out of 10. In sum, the total duration of the exercise session was 42 min in the control condition and 51 min (42 min + 9 extra min) in the experimental condition.

**2.5. Measures**

**2.5.1. Usual PA**

Usual PA before the onset of the health problem that led to the ambulatory rehabilitation was assessed at baseline using an adapted version of the "Saltin-Grimby PA Level Scale" (Grimby et al., 2015). Respondents could choose between four options used to create four self-reported PA groups: (1) physically inactive; (2) light PA; (3) regular PA and physical training; and (4) regular hard physical training for competition and sports.

**2.5.2. Affective attitudes toward PA**

These variables were assessed at baseline, at the end of the control condition (i.e., four weeks after the start of the study), and at the end of the experimental condition (i.e., eight weeks after the start of the study).

**2.5.2.1. Explicit affective attitudes toward PA**

Explicit affective attitudes toward PA were assessed using two items (Rhodes & Journeya, 2003). The stem prior to each item was "Would you say that being physically active is something ...". Participants answered on a seven-point bipolar scale from 1 (unpleasant) to 7 (pleasant) and from 1 (boring) to 7 (fun). Items were averaged to create an overall measure of affective attitudes toward PA (correlation between items = 0.93, 0.73, and 0.88 at baseline, at the end of the control condition, and at the end of the experimental condition, respectively).

**2.5.2.2. Implicit affective attitudes toward PA**

Implicit affective attitudes toward PA were assessed using an Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998), a response-time categorization task that assesses the relative strength of
automatic affective associations between PA and sedentary behavior (see Supplemental Material1 for more details). For each participant, a D-score was calculated on 2 to +2 range to assess negative or positive implicit attitudes toward PA (versus sedentary behavior). D-score ranging from 2 to +2, negative or positive indicating unfavorable and favorable implicit attitudes toward PA (versus sedentary behavior), respectively.

### 2.5.3. PA behavior

These variables were assessed daily across the eight weeks.

#### 2.5.3.1. Self-reported PA

Self-reported PA during commuting and leisure time was assessed using an adapted version of the International PA Questionnaire (IPAQ; Craig et al., 2003). Each week, participants received a notebook and were invited to provide a daily report of the time spent in moderate- to-vigorous PA, walking, and sitting. The time spent walking and moderate-to-vigorous PA was used as an outcome.

#### 2.5.3.2. Accelerometer-based measure of PA

Following recommendations in patients with PD (Mantri, Wood, Duda, & Morley, 2019), a three-axis accelerometer (Actigraph GT3X+; Pensacola, USA) was used to assess PA. Participants were given the accelerometer and related indications on the first exercise session. They were asked to return the accelerometer at the next exercise session, one week later. At the end of each exercise session, participants were given a new accelerometer. One-minute epochs were used for data analyses and non-wear time was defined as ≥59 consecutive minutes of zero counts. Daily data were included if the wear time was ≥10 waking hours per day (Evenson & Terry, 2009). Data were included if ≥4 days met the aforementioned conditions (Matthews, Ainsworth, Thompson, & Bassett Jr, 2002). The time spent in moderate-to-vigorous PA determined through previously validated cut-points (Freedson, Melanson, & Sirard, 1998) in bouts lasting at least 10 min was used as an outcome.

### 2.5.4. Other measures

Additional measures are described in Supplemental Material 2.
**2.6. Statistical analyses**

To examine the effect of the intervention (i.e., control versus experimental condition) on the affective evaluation of PA and daily-life PA, linear mixed-effects models (MEMs) were used. MEMs are well-suited to investigate longitudinal data as they allow to handle missing data and to account for the nested structure of the data (i.e., multiple observations from the same individuals over time). Moreover, statistical assumptions associated with MEM can be met even in small data paradigm (Baayen, Davidson, & Bates, 2008; Boisgontier & Cheval, 2016). Regarding statistical power, with a probability of committing a type 1 error <5% (i.e., a-rate of 0.05) and a type 2 error <10% (i.e., power 0.90), a sample size calculation using the G. Power3.1 software (Faul et al., 2007) indicated that a minimum of 32participants were required. Restricted maximum likelihood (REML) was used as it provides less biased estimates of variance components compared with full maximum likelihood (Luke, 2017) particularly in small sample size (McNeish & Stapleton, 2016). Finally, to reduce the inflated type I error rate that results from under-estimated fixed-effects standard errors in small sample size (McNeish & Stapleton, 2016), Kenward-Roger's approximations for degrees of freedom were used to calculate P-values (Kenward & Roger, 1997). An estimate of the effect size was reported using the marginal pseudo R² computed using the MuMln package (Barton, 2018). Statistical assumptions associated with MEM (normality of the residuals, homogeneity of variance, linearity, multi-collinearity, and undue influence) were checked and met for all models. The analyses were conducted in R with the lme4 and lmerTest packages (Bates, Mächler, Bolker, & Walker, 2014; Kuznetsova, Brockhoff, & Christensen, 2017; R Core Team, 2019). To reduce convergence issues, each model was first optimized using the default BOBYQA optimizer (Powell, 2009), followed by the Nelder-Mead's optimizer (Nelder & Mead, 1965), the nlimb optimizer from the optimx package (Nash & Varadhan, 2011), and then the L-BFGS-B optimizer (see Cheval et al., 2021; Cheval et al., 2020; Frossard & Renaud, 2019, for similar procedure).

To examine the evolution of explicit and implicit affective attitudes as a function of the conditions,
we used a linear MEM that included condition (baseline versus control versus experimental conditions) as
a fixed factor. The MEM specified participants as a random factor and included random effects for the
conditions. The models were adjusted for usual PA but not for age, sex, or body mass index because of the
low number of participants.

To examine the evolution of self-reported and accelerometer-based measures of PA as a function
of the conditions, we used a linear MEM that included the condition (i.e., control condition versus
experimental conditions) as a fixed factor and specified the same random structure as the one for the
models testing the evolution of affective attitudes. The models were adjusted for usual PA and for the day
of the week (i.e., Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday).

2.7. Post-hoc power analysis

Because of the small sample of our study (n = 7), we conducted a post-hoc power analysis using
G.Power 3.1 in order to evaluate the achieved power of our study (Faul, Erdfelder, Lang, & Buchner,
2007). We used a within factors ANOVA based on a medium effect size (Cohen's f = 0.25; based on
[Hutchinson et al., 2023]), a probability of committing a type 1 error <5%, 2 (PA measures) and 3 (implicit
and explicit affective attitudes) groups and measurements, and a correlation among repeated measures
of 0.80. The post-hoc power calculation indicated a power of 40% for PA behavior and 46% for explicit
and implicit attitudes.

3. Results

After the descriptive statistics, the results are reported in two sections: the first describes results
of analyses on explicit and implicit affective attitudes, and the second describes results of analyses on
self-reported and accelerometer-based measures of PA. The effect of the experimental condition on the
evaluation of the exercise sessions is presented in Supplemental Material 3.

**3.1. Descriptive statistics**

Table 1 summarizes the characteristics of the participants stratified by condition (i.e., baseline versus control versus experimental). The final sample included 7 patients with PD (72.9 ± 5.6 years, 3 women, 22.8 ± 2.9 body mass index) (Fig. 1). Most patients did regular PA before the onset of their disease (two participants were in stage 3 “regular PA” and five were in stage 2 “some PA” of the Saltin-Grimby Questionnaire). Descriptive statistics stratified by week are provided in Supplemental Table S2.
<caption>**Table 1**</caption>

*Descriptive statistics across the conditions*

<table><thead><tr><th rowspan="2">N = 7</th><th colspan="9">Conditions</th></tr><tr><th colspan="3">Baseline</th><th colspan="3">Control</th><th colspan="3">Experimental</th></tr><tr><th></th><th>Mean</th><th>SD</th><th>Range</th><th>Mean</th><th>SD</th><th>Range</th><th>Mean</th><th>SD</th><th>Range</th></tr></thead><tbody><tr><td><strong>Demographics</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>72.9</td><td>5.6</td><td>63-78</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gender (number; % women)</td><td>3</td><td>42.8%</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Body mass index (Kg/M²)</td><td>22.8</td><td>2.9</td><td>17-26</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Usual level of PA<br>(number; %)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Some physical activity</td><td>5</td><td>71.4%</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Regular physical activity</td><td>2</td><td>28.6%</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Stage of motor dependence (number; %)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Stage 3</td><td>7</td><td>100%</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Affective attitudes toward PA</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Explicit attitudes</td><td>5.9</td><td>1.1</td><td>4.5-7</td><td>5.2</td><td>0.6</td><td>4.5-6</td><td>6.2</td><td>0.9</td><td>5-7</td></tr><tr><td>Implicit attitudes</td><td>.58</td><td>1.0</td><td>-.6-1.56</td><td>.89</td><td>.99</td><td>-.68-1.65</td><td>.81</td><td>.71</td><td>-.56-1.62</td></tr><tr><td><strong>PA behavior (min per day)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Self-reported measure</td><td></td><td></td><td></td><td>148.6</td><td>80.1</td><td>57-262</td><td>199.3</td><td>111.4</td><td>5-359</td></tr><tr><td>Accelerometer-based measure</td><td></td><td></td><td></td><td>18.5</td><td>18.9</td><td>3-52</td><td>20.9</td><td>23.2</td><td>5-64</td></tr><tr><td><strong>Evaluation of each exercise session</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Perceived effort</td><td></td><td></td><td></td><td>3.8</td><td>0.7</td><td>3-6</td><td>3.6</td><td>0.5</td><td>3-5</td></tr><tr><td>Affective evaluation</td><td></td><td></td><td></td><td>6.7</td><td>1.5</td><td>0-10</td><td>6.8</td><td>2.3</td><td>0-10</td></tr></tbody></table>

*Note.* PA = physical activity; SD = standard deviation. Explicit attitudes ranged from 1 to 7, indicating unfavorable and favorable explicit attitudes toward PA, respectively. For the implicit attitudes, we used a D-score that ranges from 2 to +2, indicating negative or positive implicit attitudes toward PA (versus sedentary behavior), respectively. Perceived effort of the exercise session ranged from 0 to 10, indicating “no effort” and “very very hard” perceived effort, respectively. Affective evaluation of the exercise session ranged from 10 to +10, indicating a very pleasant or a very unpleasant affective evaluation, respectively.
<caption>**Table 2**</caption>

*Results of the mixed models predicting affective attitudes toward physical activity*

<table><thead><tr><th rowspan="2"></th><th colspan="2">Explicit attitudes</th><th colspan="2">Implicit attitudes</th></tr><tr><th colspan="2">(Likert scale from 1 to 7)</th><th colspan="2">(D score from -2 to +2)</th></tr><tr><th></th><th>b (CI)</th><th>p</th><th>b (CI)</th><th>p</th></tr></thead><tbody><tr><td colspan="5"><strong>Fixed Effects</strong></td></tr><tr><td>Intercept</td><td>5.84 (5.03;6.64)</td><td>&lt;.001</td><td>-.01 (-1.00;0.97)</td><td>.979</td></tr><tr><td colspan="5"><strong>Condition (ref. control condition)</strong></td></tr><tr><td>Experimental condition</td><td>1.00 (.36;1.64)</td><td>.022</td><td>.19 (-.41;.79)</td><td>.564</td></tr><tr><td>Baseline condition</td><td>.64 (-.15;1.43)</td><td>.163</td><td>-.16 (-.33;.01)</td><td>.163</td></tr><tr><td colspan="5"><strong>Covariates</strong></td></tr><tr><td>Usual level of physical activity (ref. regular)</td><td></td><td></td><td></td><td></td></tr><tr><td>Some light physical activity</td><td>-.87 (-1.74;.01)</td><td>.210</td><td>0.86 (.25;.1.47)</td><td>.109</td></tr><tr><td colspan="5"><strong>Random Effects</strong></td></tr><tr><td colspan="5"><strong>Participants</strong></td></tr><tr><td>Intercept</td><td>0.312</td><td></td><td>1.489</td><td></td></tr><tr><td>Condition baseline</td><td>.832</td><td></td><td>0.014</td><td></td></tr><tr><td>Condition experimental</td><td>.439</td><td></td><td>0.568</td><td></td></tr><tr><td>Corr. (Intercept, Condition baseline)</td><td>-.58</td><td></td><td>-.48</td><td></td></tr><tr><td>Corr. (Intercept, Condition experimental)</td><td>-.42</td><td></td><td>-.97</td><td></td></tr><tr><td>Corr. (Condition baseline; Condition experimental)</td><td>.98</td><td></td><td>.26</td><td></td></tr><tr><td>Residual</td><td>.155</td><td></td><td>.115</td><td></td></tr><tr><td>R<sup>2</sup></td><td>.366</td><td></td><td>.128</td><td></td></tr></tbody></table>

*Note.* CI = confidence interval at 95%. D-score ranges from -2 to +2, indicating unfavorable and favorable implicit attitudes toward physical activity (vs. sedentary behaviors), respectively. Explicit attitudes range from 1 to 7, indicating unfavorable and favorable explicit attitudes toward physical activity, respectively.
<caption>**Table 3**</caption>

*Results of the mixed models predicting daily-life physical activity*

<table><thead><tr><th></th><th colspan="2">Self-reported<br>(in min per day)</th><th colspan="2">Direct<br>(in min per day)</th></tr><tr><th></th><th>b (CI)</th><th>p</th><th>b (CI)</th><th>p</th></tr></thead><tbody><tr><td><strong>Fixed Effects</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Intercept</td><td>190.8 (79.3;302.2)</td><td>.025</td><td>40.7 (26.7;54.7)</td><td>.003</td></tr><tr><td><strong>Condition (ref. control condition)</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Experimental condition</td><td>36.5 (-3.22;76.2)</td><td>.122</td><td>2.3 (-2.6;7.11)</td><td>.417</td></tr><tr><td><strong>Covariates</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Day (ref. Sunday)</td><td></td><td></td><td></td><td></td></tr><tr><td>Monday</td><td>16.3 (-11.2;43.9)</td><td>.245</td><td>3.7 (-3.9;11.2)</td><td>.342</td></tr><tr><td>Tuesday</td><td>27.3 (-3.5;54.8)</td><td>.053</td><td>-2.3 (-9.8;5.1)</td><td>.539</td></tr><tr><td>Wednesday</td><td>26.3 (-1.3;53.8)</td><td>.063</td><td>1.8 (-5.6;9.2)</td><td>.638</td></tr><tr><td>Thursday</td><td>10.4 (-17.3;38.0)</td><td>.459</td><td>-5.0 (-12.4;2.4)</td><td>.186</td></tr><tr><td>Friday</td><td>24.7 (-2.8;52.3)</td><td>.080</td><td>.63 (-6.9;8.1)</td><td>.870</td></tr><tr><td>Saturday</td><td>-2.7 (-30.3;24.8)</td><td>.848</td><td>-2.9 (-10.4;4.6)</td><td>.456</td></tr><tr><td>Usual level of physical activity (ref. regular)</td><td></td><td></td><td></td><td></td></tr><tr><td>Some light physical activity</td><td>-59.6 (-185.9;66.7)</td><td>.467</td><td>-31.9 (-47.6;-16.3)</td><td>.028</td></tr><tr><td><strong>Random Effects</strong></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Participants</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Intercept</td><td>6806</td><td></td><td>72.95</td><td></td></tr><tr><td>Condition experimental</td><td>2466</td><td></td><td>10.13</td><td></td></tr><tr><td>Corr. (Intercept, Condition experimental)</td><td>.50</td><td></td><td>1.00</td><td></td></tr><tr><td>Residual</td><td>5333</td><td></td><td>284.89</td><td></td></tr><tr><td>R<sup>2</sup></td><td>.072</td><td></td><td>.354</td><td></td></tr></tbody></table>

*Note.* CI = confidence interval at 95%. Self-reported physical activity was assessed using an adapted version of the International Physical Activity Questionnaire and was expressed in minutes per day. Accelerometer-based measure of physical activity was expressed in minutes per day. The parameter for the correlation between random intercept and random slope is estimated at 1.00 in the model, which is explain by the low number of participants included in the models.
## 3.2. Effect of the intervention on the affective attitudes toward PA

### 3.2.1. Explicit affective attitudes

Explicit affective attitudes toward PA were significantly more positive after the four weeks of the experimental condition than after the four weeks of the control conditions (b = 1.00, 95% CI = 0.36 to 1.64, *P* = 0.022). No significant difference was observed between baseline and the control (b = 0.64, 95%CI = 0.15 to 1.43, *P* = 0.163) or experimental condition (b = 0.36, 95%CI = 0.10 to 0.82, *P* = 0.182). The variables under consideration explained 36.6% of the variance in the explicit affective attitudes toward PA (Tab. 2). As illustrated in Figure 2A, the evolution of the explicit attitudes seems to follow a quadratic pattern in which these attitudes first decreased from baseline to the end of the control condition and increased from the end of control condition to the end of the experimental condition. To formally test this evolution, an additional model using polynomial contrasts was conducted. This model included a linear (1 for baseline, 0 for the control condition, and +1 for the experimental condition) and a quadratic (1 for baseline, 2 for the control condition, and +1 for the experimental condition) orthogonal contrast. Results revealed a significant effect of the quadratic contrast only (*P* = 0.014). In other words, this model confirms that explicit affective attitudes followed the aforementioned quadratic pattern.

### 3.2.2 Implicit affective attitudes

No significant difference in implicit affective attitudes was observed between the control condition and baseline (b = 0.16, 95%CI=0.33 to 0.01, *P* = 0.163), between the control condition and the experimental condition (b = 0.19, 95%CI = 0.41 to 0.79, *P* = 0.564), or between baseline and the experimental condition (b = 0.37, 95% CI = 0.20 to 0.96, *P* = 0.272) (Tab. 2; Fig. 2B). A model testing the pattern of evolution of the implicit attitudes using the aforementioned polynomial contrasts showed that neither the linear (*P* = 0.366) nor the quadratic (*P* = 0.747) contrasts were significant, thereby confirming that implicit attitudes did not significantly change as a function of condition.
<caption>**Figure 2**</caption>

Affective attitudes toward PA

<figure><img src="image_4.png" /></figure>

*Note.* A = explicit attitudes toward PA; B = implicit attitudes toward PA. Dots represent the observations for each participant. Grey lines represent each participant's evolution of the attitudes across conditions. These lines are represented when patients have two consecutive measurement points. The black line represents the averaged evolution of the attitudes across conditions. For the implicit attitudes, we used a D-score that ranges from 2 to +2, indicating negative or positive implicit attitudes toward PA (versus sedentary behavior), respectively. For the explicit attitudes, we used a scale ranging from 1 to 7, indicating negative or positive explicit attitudes toward PA, respectively.

### 3.3. Effect of the intervention on daily-life PA

#### 3.3.1. Self-reported measure

No significant difference was observed in self-reported moderate-to-vigorous PA between the four weeks of the control condition and the four weeks of the experimental condition (b=36.6min per day, 95%CI=3.2 to 76.2; P = 0.122) (Tab. 3; Fig. 3A).
<figure><img src="image_5.png" /><figcaption>**Figure 3**

*Daily life PA*</figcaption></figure>

*Note.* A = self-reported measure of PA; B = Accelerometer-based measure of PA. Dots represent the observations for each participant. Grey lines represent each participant's evolution of the attitudes across conditions. The black line represents the averaged evolution of the PA across conditions.

### 3.3.2. Accelerometer-based measure

No significant differences were observed in accelerometer-based moderate-to-vigorous PA between the four weeks of the control condition and the four weeks of the experimental condition (b = 2.3min per day, 95% CI= 2.6 to 7.11, P = 0.417). Participants who usually performed some PA before the onset of PD exhibited a lower level of accelerometer-based moderate-to-vigorous PA compared with participants who usually performed regular PA (b = 31.9 min per day, 95%CI = -47.6 to -16.3, P = 0.028) (Tab. 3).
# 4. Discussion

## 4.1. Main findings

The present study investigated whether manipulating the intensity of the effort at the end of an exercise session enhances affective attitudes toward PA and promotes daily-life PA behavior in patients with PD. The findings revealed that adding a 9-min period of lower physical effort intensity at the end of a weekly exercise session over four weeks improved explicit affective attitudes toward PA. It is worth noting that, all other things being equal, the experimental condition is more demanding than the control condition both in terms of time duration and total effort to be invested. Consequently, the observation that the experimental condition improves the affective attitudes is consistent with the notion that humans have a bounded rationality (Simon, 1990) and use affective heuristics (or biases) to evaluate a given experience (Finucane, Alhakami, Slovic, & Johnson, 2000). No significant effects of the experimental condition were found on the other outcomes (i.e., implicit attitudes and PA), although results are in the expected direction for self-reported PA (see below).

## 4.2 Comparison with other studies

Our results are in line with previous studies testing the peak-end rule hypothesis in PA (Hargreaves & Stych, 2013; Hutchinson et al., 2020; Zenko et al., 2016). However, whereas prior studies examined the effect on the affective evaluation of a single exercise session, the present study assessed the effect on the affective evaluation of PA in general. Hence, our study provides preliminary evidence that interventions based on the peak-end rule can enhance the affective determinants of PA (Rhodes et al., 2019; Stevens et al., 2020; Williams & Bohlen, 2019). However, given the sample size, the statistically significant effect on explicit affective attitudes could be due to type 1 error and should be interpreted with caution.

In line with a previous study exploring the peak-end rule in PA (Hargreaves & Stych, 2013), we did not observe that the experimental condition was associated with a significant higher level of self-reported moderate-to-vigorous PA. Nevertheless, although non-significant, participants self-reported an additional 36min per day of daily-life moderate-to-vigorous PA over the four weeks of the experimental condition compared with the control condition. This result is promising but needs to be considered in light of the
study design, which cannot determine if the effect observed is explained by the condition or by the effect
of time (i.e., the participation in an exercise program). The latter seems to be supported by the evolution
of PA across the eight weeks (Fig. S1).

We found no significant evidence that effort manipulation had an impact on implicit affective attitudes or device-measured PA. This non-significant effect on implicit affective attitudes is consistent with the Hutchinson et al.'s study (Hutchinson et al., 2023). In contrast, at the explicit level, we observed a significant and positive effect of the effort manipulation on explicit affective attitudes toward PA. This result stands in contrast with the one observed in the study of Hutchinson et al. (Hutchinson et al., 2023). Yet, it should be noted that, although not significant, results were in the same direction, showing that participants ending with a lower level of effort tend to exhibit higher explicit affective attitudes toward physical activity than participants ending with a higher level of effort. Moreover, this difference can be also explained by the nature of the exercise (resistance versus aerobic) or of the type of effort manipulation (decreasing intensity throughout the session versus adding a lower effort intensity at the end).

Regarding the differences between implicit and explicit measure of affective evaluation of PA could
be explained by the fact that the automatic processes could be less malleable than the controlled
processes (Joy-Gaba & Nosek, 2010). For example, in line with this suggestion, studies showed that explicit
attitudes are more readily to change with relatively few exposures to counter-attitudinal examples, while
implicit associations required more exposures to evolve (Rydell & McConnell, 2006; Rydell, McConnell,
Strain, Claypool, & Hugenberg, 2007). Consequently, longer interventions would have been necessary to
modify implicit affective associations with PA.

The difference in the effect size observed between self-reported and accelerometer-based
measure of PA (i.e., ~36 min versus ~2 min per day) may be explained by at least two features. First, these
measures did not assess the same type of PA. The questionnaire measured the time spent walking and in
moderate-to-vigorous PA, irrespective of their duration, while the accelerometer-based measure only
included moderate-to-vigorous PA behavior that last a minimum of 10 min. Second, it has been shown
that self-reported measures of PA often overestimate PA levels, in comparison with accelerometer-based
measures (Prince et al., 2008; Skender et al., 2016), especially in patients with PD (Mantri et al., 2019).

**4.3. Strengths and weaknesses**

Among the strengths of the present study are the application of the end effect of the peak-end
rule principle, a clinical sample of patients with PD, a longitudinal design (i.e., repeated measurements
over eight weeks), the measure of both explicit and implicit affective attitudes toward PA, and the use of
both self-reported and accelerometer-based measures of daily-life PA. This study also has some
limitations. First, our study relied on a small sample size (n = 7) and did not reach a power of 80%.
Accordingly, although we used a statistical approach adapted to small samples of participants (Luke, 2017;
McNeish & Stapleton, 2016), our underpowered study can bias the effects size estimated (Brysbaert,
2019). Second, this work was an early-phase study aiming to test the potential impact of an intervention
anchored in the peak-end rule principle, but it did not meet the criteria of a formal randomized controlled
trial. Specifically, our study was drawn on a within-subjects design in which all patients first performed the
four weeks of the traditional exercise rehabilitation program and then performed the four weeks of the
experimental program. Accordingly, we cannot rule out the possibility that the effects observed were due
to an effect of time rather than to the condition. For example, patients' cardiorespiratory fitness
improvement over the training sessions or patients' habituation to the exercise may also impact their
perceived effort and affective experiences. Future studies using either a random order for the
experimental conditions or a between-subject randomization are needed to eliminate such possibility.
Finally, four to seven of the participants were taking levodopa medication. Levodopa intake may lead to
random fluctuations in their motor performance, called the "on-off" phenomenon (Nutt, Woodward,
Hammerstad, Carter, & Anderson, 1984). These fluctuations are likely to affect patients' daily-life PA,
irrespective of their affective evaluation of PA, and should therefore be monitored and accounted for in
future research.
## 5. Conclusion

In this study, we tested a manipulation that simply consists of adding a “better (less intensive) end” with all other things being equal. Our findings provide preliminary evidence that an intervention manipulating the effort intensity at the end an exercise session may be effective to enhance explicit evaluation of PA. If these results are confirmed by a randomized controlled trial, this free and easily-deliverable intervention could be rapidly implemented on a large scale to promote PA among patients with PD and other diseases.

## Authors' contributions

L.F.: conceptualization, original draft; P.S.: conceptualization, writing-review and editing; S.M.: writing-review and editing; A.S.: conceptualization, writing - review and editing; B.C.: conceptualization, supervision, writing - original draft.

## Data availability statement

The data that support the findings of this study are available at https://zenodo.org/record/4742001#.ZAr-FsGZMQM and https://aspredicted.org/see_one.php.

The Supplementary Material is available at https://www mov-sport-sciences.org/10.1051/sm/2023009/olm.

## Acknowledgments

L.F. is funded by the French Ministry of Higher Education, Research and Innovation. B.C. is supported by an Ambizione grant (PZ00P1_180040) from the Swiss National Science Foundation (SNSF). The authors are thankful to the La Lignière clinic for providing support on the study implementation. The authors are thankful to the patients.

## Conflicts of interest

The authors declare that they have no conflicts of interest in relation to this article.

## Consent to participate

All the participants agreed to participate and signed a written informed consent.

## Consent for publication

All the authors listed in the by-line have agreed to the by-line order and to the submission of the manuscript in this form.

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Il est important de noter que certaines terminologies employées dans cette contribution peuvent
différer de celles utilisées dans ce travail doctoral. Les termes « attitudes affectives implicites » (*implicit
affective attitudes*) et « évaluation affective globale de la session » (*global affective evaluation of the
session*) mentionnés dans cet article correspondent aux « évaluations affectives automatiques » et à l‘«
affect remémoré » utilisés tout au long de ce manuscrit, respectivement.

Cet article a été publié dans le journal *Movement & Sport Sciences - Science & Motricité*. L'article a été formaté selon les normes de l'American Psychological Association (APA), conformément aux exigences du journal. **Le matériel supplémentaire est disponible gratuitement au lien suivant:**

https://zenodo.org/records/13954495

**Référence :** Fessler, L., Sarrazin, P., Maltagliati, S., Smeding A., & Cheval, B. (2024). All's well that ends well: an early-phase study testing lower end-session exercise intensity to promote physical activity in patients with Parkinson's disease. *Movement & Sport Sciences-Science & Motricité*, 123, 17–31. https://doi.org/10.1051/sm/2023009