Enhancing Adherence to Home-Based Expiratory Muscle Strength Training in Parkinson Disease: Randomized Controlled Trial of an mHealth Intervention

TL;DR

A mobile app helped Parkinson's patients stick to breathing exercises longer and improved their lung strength more than traditional methods.

Contribution

First randomized trial integrating mHealth with expiratory muscle strength training to improve long-term adherence in Parkinson's disease.

Findings

mHealth-assisted EMST led to higher adherence and greater expiratory muscle strength gains than conventional EMST.

Participants using the app completed significantly more breathing exercises during unsupervised training.

Digital support via SpiroGym improved self-efficacy and physiological outcomes in Parkinson's patients.

Abstract

Aspiration pneumonia is a leading cause of death in Parkinson disease (PD). Expiratory muscle strength training (EMST) is a promising intervention for respiratory and swallowing dysfunction. However, long-term EMST adherence is frequently poor in PD.

This study aims to determine whether mobile health (mHealth)–assisted EMST with the SpiroGym app (Czech Technical University) improves long-term adherence and physiological outcomes versus conventional EMST among participants at risk for nonadherence.

In this single-center, parallel, phase 2 randomized controlled trial, 75 individuals with PD were randomized 1:1 to conventional EMST (control; n=38) or the same protocol enhanced with the SpiroGym app (experimental; n=37), using a simple computer-generated randomization sequence. The SpiroGym is an mHealth app that provides real-time performance monitoring, direct visual feedback, and longitudinal progress tracking. All participants completed 8 weeks of semisupervised intensive EMST with biweekly in-person reassessments, followed by 16 weeks of unsupervised maintenance training. The primary outcome was adherence during weeks 8 to 24 among participants at risk for nonadherence, defined a priori at week 8 as Self-Efficacy for Home Exercise Program Scale (SEHEPS) less than 59. Because risk status was determined at week 8 and all participants subsequently entered the unsupervised phase, individuals not classified as at-risk were not excluded. Their data from week 8 onward were reported alongside the at-risk group. Secondary outcomes were changes in maximum expiratory pressure and SEHEPS.

No study-related adverse events occurred. Groups were well matched at baseline (control vs experimental: mean disease duration 7.0 (SD 5.7) vs 7.3 SD 4.7) y; mean Hoehn-Yahr 1.97 (SD 0.6) vs 2.0 (SD 0.5)). The mixed-effects model showed no significant 3-way interaction (group×interval×SEHEPS risk; P=.14). At week 24, the at-risk category for the nonadherence cohort comprised 34 participants (control, n=17; experimental, n=17). In this at-risk cohort, the experimental group demonstrated a smaller decline in adherence during weeks 8 to 24 than controls (β=496.9, 95% CI 130.7‐863.3; P=.008), completing 1073 (95% CI 643‐1502) expiratory maneuvers versus 525 (95% CI 358‐692). Maximum expiratory pressure increased in both groups from weeks 0 to 24, with larger gains in the experimental group (+43.1, 95% CI 32.4‐53.8 cmH₂O) than in controls (+22.8, 95% CI 13.8‐31.8 cmH₂O; P=.006; Cohen d=0.74). SEHEPS improved after intensive training in both groups, but only the experimental group exceeded the 12-point minimal detectable change at the 95% confidence limit.

This is the first randomized controlled trial to integrate mHealth with EMST. Unlike prior studies in the EMST field, we focused on sustaining long-term exercise adherence. SpiroGym-assisted EMST resulted in higher long-term adherence and greater gains in expiratory muscle strength than conventional EMST. In real-world PD care, assessing self-efficacy after the supervised EMST phase may help identify individuals who would benefit from digital support, making mHealth-assisted EMST a practical approach for maintaining exercise adherence.

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